lunibia  ©mbetJöJttp 
ttttljeOutpodlttogark 

QIoIbgF  of  pijgBtrianB  anö  burgeons 


un 


ELEMENTS   OF  CLIXICAL  DIAGNOSIS 


h5?><9>Äo 


s  ^^   o 


THE  ELEMENTS 


OP 


CLINICAL    DIAGNOSIS 


BY 

PROFESSOR  DR.   G.   KLEMPERER 

PROFESSOR   OF   MEDICINE   AT   THE   UNIVERSITY  OF  BERLIN 


iFirgt  American  from  tje  Äcömtjj  (last)  (German  lEtiition 

WITH  SIXTY-ONE  ILLUSTRATIONS 
AUTHORIZED    TRANSLATION 

BY 

NATHAN  E.  BRILL,  A.M.,  M.D. 

ADJUNCT   ATTENDING   PHYSICIAN,    MOUNT   SINAI   HOSPITAL,   NEW   YOEK   CITY 

AND 

SAMUEL  M.  BRICKNER,  A.M.,  M.D. 

ASSISTANT  GYNJECOLOÖI8T,   MOUNT  SINAI   HOSPITAL,   OUT-PATIENT  DEPAKTMENT 


THE    MACMILLAN    COMPANY 

LONDON:   MACMILLAN  &   CO.,  Ltd. 
1898 

All  rights  reserved 


COPTEIGHT,   1898, 

By  the  MACMILLAN  COMPANY. 


Nortoooö  ^rrg8 

J.  S.  Cashing  &  Co.  —  Berwick  &  Smith 
Norwood  Mass.  U.S.A. 


DEDICATED    TO 

Priög  Counstllor  '^xottmox  ©r.  3£.  Eegtien 

DIRECTOR   OF   THE    FIRST    MEDICAL   CLINIC 

ON    THE 

OCCASION    OF    THE   JUBILEE    IN    CELEBRATION   OF 

THE    COMPLETION    OF    HIS 

TWENTY-FIVE    YEARS    OF    SERVICE 

AS    A    CLINICAL    TEACHER 

APRIL  6,   1890 


Digitized  by  the  Internet  Archive 

in  2010  with  funding  from 

Open  Knowledge  Commons 


http://www.archive.org/details/elementsofclinicOOklem 


AUTHOR'S   PREFACE   TO   THE   FIRST  AMERICAN 

EDITION 

Of  the  great  number  of  American  physicians  who  annu- 
ally visit  the  clinics  of  Germany,  not  a  few  have  taken  my 
diagnostic  course,  the  fundamental  principles  of  which  are 
contained  in  this  little  book. 

May  this  translation  renew  the  memories  of  mutual  work 
in  the  minds  of  many  of  my  colleagues,  and  add  its  modest 
share  in  strengthening  the  relations  between  American  and 
German  intellectual  life. 

G.    KLEMPERER. 

Berlin,  November  30,  1897. 


AUTHOR'S   PREFACE   TO   THE   FIRST   EDITION 

In  this  little  book  the  rules  governing  the  clinical  diag- 
nosis of  medical  cases  which  are  in  vogue  in  the  first  medi- 
cal clinic  of  Berlin,  are  repeated.  The  same  methods  have 
characterized  my  didactic  work  since  its  inception. 

I  am  but  returning  that  which  I  learned  in  my  happy 
student  days,  when  I  add  this  modest  little  book  to  the 
offerings  of  homage  which  my  esteemed  chief  will  receive 
from  his  thankful  pupils  on  the  day  of  his  clinical  jubilee. 

G.    KLEMPERER. 
Berlin,  March  15,  1890. 

vii 


AUTHOR'S   PREFACE   TO   THE   SEVENTH 
EDITION 

The  present  edition  has  undergone  several  additions  and 
changes  which  were  made  necessary  by  the  progress  in  the 
diagnosis  of  internal  diseases. 

The  chapter  on  the  Röntgen  rays  is  new. 

G.    KLEMPERER. 
Berlin,  July  15,  1897. 


TRANSLATORS'    PREFACE 

In  offering  Klemperer's  well-known  work  to  the  Ameri- 
can medical  public,  we  feel  that  no  better  opportunity  than 
this  could  be  found  to  express  our  own  admiration  for  the 
excellence  of  the  book  in  the  original  language.  The  fact 
that  in  seven  years  the  book  has  seen  as  many  editions  in 
German,  certainly  calls  for  no  further  comment  upon  its 
virtue  from  us. 

We  have  followed  the  original  plan  of  Klemperer's  work 
throughout,  retaining  not  only  its  form,  but  most  of  the 
illustrations  and  the  continental  terms.  We  feel  justified 
in  adhering  to  the  Latin  names  of  diseases  and  of  technical 
terms,  since  it  will  familiarize  students  with  them,  and 
facilitate  their  subsequent  medical  reading  and  study.  The 
simple  explanation  that  we  desired  to  maintain,  as  far  as 
possible,  the  original  form  of  the  work,  is  sufficient  apology 
—  if  apology  need  be  —  for  using  the  terse  phraseology  in 
descriptions  of  diseases  and  conditions. 

Where  new  illustrations  have  been  substituted,  it  has 
been  done  only  for  the  sake  of  clearness. 

If  the  English  translation  of  Klemperer's  work  shall 
prove  as  helpful  to  the  medical  profession  of  the  United 
States  as  its  German  analogue  has  to  us,  we  shall  feel  amply 
repaid  for  our  labor. 

N.    E.   BRILL, 

S.    M.  BRICKNER. 

New  York,  December  1,  1897. 

ix  .   . 


TABLE   OF   CONTENTS 

PAGE 

The  Method  of  Diagnostic  Examination        ....  1 

CHAPTER   I 

Anamnesis  and  General  Condition          .....  4 

CHAPTER    II 

Diagnosis    of    the    Acute    Febrile    and    Acute    Infectioi's 

Diseases 16 

Special  Sj^mptomatology 21 

CHAPTER   III 

Diagnosis  of  the  Diseases  of  the  Nervous  System      .        .  33 

Special  Symptomatology 67 

CHAPTER   IV 

Diagnosis  of  Diseases  of  the  Digestive  System  ...  70 

Diagnosis  of  Stomach  Diseases  ......  75 

Special  Symptomatology      .         .         .         .         .         .90 

Diagnosis  of  the  Diseases  of  the  Intestines  and  Peritoneum  91 

Special  Symptomatology      ......  99 

Diagnosis  of  the  Diseases  of  the  Liver 100 

Special  Symptomatology 103 

Diagnosis  of  Enlargement  of  the  Spleen    .         .         ,         .  106 

xi 


xii  CONTENTS 

CHAPTER  V 

PAÖK 

Diagnosis    of    the    Diseases    of    the    Upper    Air-passages 

(Nose,  Throat,  Larynx) 107 

Special  Symptomatology 114 

CHAPTER   VI 

Diagnosis  of  the  Diseases  of  the  Respiratory  Tract        .  121 

Percussion  of  the  Thorax 129 

Auscultation  of  the  Thorax 136 

Examination  of  the  Sputum 141 

Special  Symptomatology 151 

CHAPTER   VII 

Diagnosis  of  Diseases  of  the  Circulatory  System      .         .  160 

The  Pulse 171 

Special  Symptomatology 176 

CHAPTER  VIII 

Examination  of  the  Urine        .        .         .         .  ^      ,        .        .  181 

CHAPTER   IX 

Diagnosis  of  Diseases  of  the  Kidney    .....  220 

Diffusive  Diseases  of  the  Kidneys 220 

Other  Diseases  of  the  Kidneys   ......  224 

Examination  of  Renal  and  Vesical  Calculi          .        .         .  226 

CHAPTER    X 

Diagnosis  of  Disorders  of  Metabolism           ....  229 


CONTENTS  Xlil 
CHAPTER   XI 

PAGE 

Diagnosis  of  Diseases  of  the  Blood 241 

Special  Symptomatology 250 

CHAPTER  XII 

Animal  and  Vegetable  Parasites 253 

CHAPTER   XIII 

The  Röntgen  Rays  as  Diagnostic  Aids           ....  278 


The  "  Status  of  the  Nervous  System,"  on  page  33,  is  edited  by 
Professor  Dr.  Goldscheider  of  Berlin. 

The  illustrations  were  drawn  by  Dr.  Johannes  Mann  of  Leo- 
poldshall,  mostly  from  his  own  specimens,  in  part  from  older  speci- 
mens and  drawings  of  Professor  Leyden. 

Figures  53  to  61  have  been  taken,  by  permission,  from  the  micro- 
photographic  Atlas  of  Franke L  and  Pfeiffer. 


LIST   OF   ILLUSTRATIONS 


FIG. 

1.  Fever  Curve  in  Measles 

2.  Fever  Curve  in  Scarlatina    .         .         .         ... 

3.  Fever  Curve  in  Erysipelas    ....... 

4.  Fever  Curve  in  Pneumonia  ;  crisis  4tli  to  5th  day 

5.  Fever  Curve  in  Pneumonia  ;  pseudocrisis  on  the  3d,  crisis 

on  the  11th  day       ..... 

6.  Schematic  Fever  Curve  in  Typhoid  Fever     . 

7.  Fever  Curve  in  Typhus  Fever 

8.  Fever  Curve  in  Relapsing  Fever  , 

9.  Fever  Curve  in  Variola  .         .         . 

10.  Fever  Curve  in  Varioloid      .... 

11.  Fever  Curve  in  Quotidian  Intermittent  Fever 

12.  Fever  Curve  in  Tertian  Intermittent  Fever  . 

13.  Fever  Curve  in  Quartan  Intermittent  Fever 

14.  External  Surface  of  the  Left  Cerebral  Hemisphere 

15.  Outline  of  a  Transverse  Dorso-ventral  Section  of  the  Right 

Half  of  the  Brain 

16.  Diagrammatic   Cross-section  of  the  Spinal  Cord,  showing 

the  Tracts  of  the  White  Matter 

17.  The  Base  of  the  Brain  and  the  Cranial  Nerves 

18.  Points  for  Electric  Stimulation  of  the  Nerves  of  the  Head, 

Face,  and  Neck       ........ 

19.  Points  for  Electric  Stimulation  of  the  Nerves  of  the  Flexor 

Surface  of  Arm,  Forearm,  and  Hand      .... 

20.  Points  for  Electric  Stimulation  of  the  Nerves  of  the  Exten- 

sor Surface  of  Arm,  Forearm,  and  Hand 

XV 


PAGE 

21 
22 

22 
23 

23 
24 

25 
26 

26 
27 
28 
28 
29 
38 

39 

41 
46 

61 

62 


xvi  ILLUSTRATIONS 

KKi.  •  PAÖK 

2L     Points  for  Electric  Stimulation  of  the  Nerves  of  the  Exten- 
sor Surface  of  the  Thigh  and  Leg 64 

22.  Points  for  Electric  Stimulation  of  the  Nerves  of  the  Flexor 

Surface  of  the  Thigh,  Leg,  and  Foot 

23.  Schematic  Microscopic  Picture  of  Vomitus  . 

24.  Relative  Positions  of  the  Stomach,  Liver,  and  Colon    . 

25.  The  Various  Paralyses  of  the  Vocal  Cords  . 

26.  Relative  Positions  of  Thoracic  Viscera 

27.  Morning  Sputum  of  Chronic  Bronchitis,  containing  no  Path- 

ological Elements 

28.  Asthma  Crystals 

29.  Curschmann's  Spirals 

30.  Sphygmographic  Tracing  of  the  Radial  Artery  of  a  Healthy 

Young  Man      ........ 

3L     Sphygmographic  Tracing  of  the  Radial  Artery  in  Aortic  In- 
sufficiency          . 

32.  Sphygmographic  Tracing  of  the  Radial  Artery  in  Aortic 

Stenosis 

33.  Sphygmographic  Tracing  of  the  Radial  Artery  in  Mitral 

Stenosis 

34.  Improvised  Fermentation  Apparatus  (Moritz) 

35.  Urinary  Deposits  in  Acid  Urine 

36.  Sediment  of  Urine  in  Acute  Yellow  Atrophy  of  the  Liver 

37.  Sediment  of  Ammoniacal  Urine 

38.  Sediment  in  Acute  Nephritis 

39.  Sediment  in  Chronic  Nephritis 

40.  The  Blood  in  Pernicious  Anaemia         .         •        .         . 

41.  Schematic  Representation  of  Various  Kinds  of  Leucocytes 

42.  Microscopic  Picture  of  Tsenia  solium  (Head,  Proglottides, 

Egg) 

43.  Microscopic  Picture  of  Tsenia  saginata  (Head,  Proglottides, 

Egg) 

44.  Microscopic  Picture  of  Bothriocephalus  latus  (Head,  Pro- 

glottides, Egg) 


ILLUSTRATIONS 


XVll 


FIG.  PAGE 

45.  Echinococcus  Membrane  and  Hooklets         ....  258 

46.  Egg  of  Distoma  hepaticum 258 

47.  Egg  of  Distoma  haematobium 258 

48.  Egg  of  Ascaris  lumbricoides 259 

49.  Egg  of  Oxyuris  vermicularis 259 

50.  Egg  of  Anchylostoma  duodenale  ......  260 

51.  Egg  of  Trichocephalus  dispar       ......  260 

52.  Trichinse  in  Muscle 261 

53.  Staphylococci 268 

54.  Streptococci 269 

55.  Gonococci 269 

56.  Pneumococci 271 

57.  Pure  Culture  of  Typhoid  Bacilli 271 

58.  Pure  Culture  of  Cholera  Bacilli 273 

59.  Bacilli  in  Tubercular  Sputum 274 

60.  Spirilla  from  a  Case  of  Relapsing  Fever  during  the  Eever    .  275 

61.  Diphtheria  Bacilli 276 


THE 

ELEMENTS  OF  CLINICAL  DIAGNOSIS 


>>«<0-0- 


THE    METHOD    OF   DIAGNOSTIC 
EXAMINATION 

The  tasks  of  practical  medicine  are  prophylactic  and 
curative.  A  systematic  treatment  of  disease  rests  upon  the 
recognition  of  its  forms  and  manifestations.  The  science 
involved  in  the  recognition  of  disease  is  called  diagnosis. 

A  complete  diagnosis  includes :  (1)  The  naming  of  the 
disease,  i.e.,  its  classification  or  place  in  some  particular 
group  of  diseases ;  (2)  the  recognition  of  the  stage  of  the 
disease,  peculiarities  or  complications ;  (3)  the  appreciation 
and  estimation  of  dangers  existing  or  liable  to  arise. 

A  diagnosis  is  reached  by  the  examination  of  the  patient. 
This  consists  in  the  obtaining  of  the  history  (anamnesis)  and 
in  the  objective  examination  (status  prajsens).  It  is  always 
advisable  to  follow  the  order  of  a  systematic  scheme  in  order 
to  avoid  mistakes  of  omission. 

The  following  scheme  of  examination  has  long  been  used 
in  the  first  medical  clinic  of  Berlin :  — 

Name,  age,  civil  condition.     Date  of  examination. 
Anamnesis : 

1.  Hereditary  relations. 

2.  Diseases  of  childliood,  menstruation. 

3.  General  conditions  of  life,  occnpation. 

4.  Previous  diseases,  puerperia. 

5.  Present  ilhiess,  its  prodromata  and  suspected  cause. 

15  1 


2         THE   METHOD   OF   DIAGNOSTIC   EXAMINATION 

6.  The  first  phenomena  of  the  disease.     (Chills  and  fever?   Sub- 

jective complaints,  functional  disturbances.) 

7.  Course  of  the  disease  to  date. 

8.  How  long  did  it  increase  in  severity?    Has  it  been  better  or 

worse  ? 

9.  Previous  treatment. 

10.    Complications  :  data  of  patient  as  to  the  principal  functions; 
e.g.,  sleep,  appetite,  cough,  expectoration,  urine,  etc.,  con- 
dition of  nutrition  and  strength,  appearance. 
Status  praesens. 

A.  General  Examination. 

I.    Constitution  (stature,  osseous  system,  muscles,  fat). 
II.   Position  (active  or  passive,  recumbent  position,  etc.). 

III.  Face. 

1.  Color  (cheeks,  lips,  conjunctivae). 

2.  Nutrition,  congestion. 

3.  Expression. 

4.  General  appearance. 

IV.  Skin. 

1.  Color  (p.  7). 

2.  Eruptions,  oedema,  scars,  decubitus. 

3.  Moist  or  dry. 

4.  Temperature  and  its  distribution. 
V.    Pulse. 

1.  Frequency,  rhythm. 

2.  Condition  of  the  arteries  (straight,  tortuous,  scle- 

rosed) . 

3.  Tension  of  the  arteries. 

4.  Pulse-wave. 

VI.    Respiratory  frequency  and  rhythm. 
VII.    Striking  symptoms. 
VIII.    Complaints  of  the  patient. 

B.  Special  Examination. 

T.    Nervous  system. 

1 .  Sensorium  (free  or  stuporous). 

2.  Headache,  vertigo. 

3.  Sleep. 

4.  Tremor. 

5.  Delirium,  abnormal  moodiness. 

6.  Disturbances  of  sensation  and  motility. 
II.    Digestive  system. 

1.    Lips,  tongue. 


THE   METHOD   OF   DIAGNOSTIC    EXAMINATION  3 

2.  Throat. 

3.  Appetite. 

4.  Thirst. 

5.  Vomiting. 

6.  Stools. 

7.  Palpation    of   the    abdomen    (painful    areas?    tu- 

mors?), the  liver  and  spleen. 

8.  Percussion  of  the  abdomen  (stomach,  liver,  spleen, 

tumors) . 

9.  Examination  of  stomach  contents. 

III.  Respiratory  system. 

1.  Rhythm  of  respiration. 

2.  Shape  of  thorax. 

3.  Respiratory   movements    (frequency,  type,   ampli- 

tude, unilateral). 

4.  Cough  and  expectoration 

5.  Percussion. 

6.  Auscultation. 

7.  Pectoral  fremitus  and  bronchophony. 

IV.  Circulatory  apparatus. 

1 .  Inspection  of  the  cardiac  area. 

2.  Inspection  of  the  large  vessels. 

3.  Palpation  of  the  cardiac  impulse. 

4.  Palpation  of  the  apex  beat. 

5.  Percussion  of  the  heart. 

6.  Auscultation  of  the  heart. 

7.  Auscultation  of  the  large  vessels. 
V.    Urine. 

1.  Voluntary,  painful  evacuation. 

2.  Amount  in  24  hours. 

3.  Specific  gravity. 

4.  Color,  clearness. 

5.  Reaction. 

6.  Albumin,  sugar. 

7.  Sediment  and  its  contents. 

Note.  —  The  beginner  will  do  well  to  learn  this  or  some  similar  scheme 
well  and  to  adhere  to  its  order  in  all  his  examinations.  The  experienced 
physician  determines  the  general  condition  in  a  few  minutes  while  asking 
the  patient  the  necessary  questions.  Through  the  general  condition  and 
the  history,  attention  will  be  directed  diagnostieally  toward  certain  organs 
or  systems  of  organs  with  which  the  special  examination  is  then  begun. 
The  organ  found  diseased  must  be  examined  with  the  greatest  care ;  so  far 
as  the  other  organs  are  concerned,  the  determination  of  their  main  features 
is  sufficient. 


CHAPTER    I 

ANAMNESIS   AND   GENERAL   CONDITION 

1.  Anamnesis. — An  exact  history  of  a  case  is  of  the 
greatest  importance ;  for,  frequently,  the  decision  of  a  diag- 
nosis hinges  upon  it. 

Hereditary  taint  is  especially  significant  in  the  diagnosis  of 
phthisis  and  the  nervous  diseases. 

The  causes  of  a  present  illness  may  lie  in  the  sequelae  of  some 
previous  disease ;  e.g.,  scarlatina  may  be  productive  of  an  acute, 
more  rarely  of  a  chronic,  nephritis;  an  articular  rheumatism  may 
lead  to  a  valvular  endocarditis ;  repeated  attacks  of  bronchitis  and 
asthma  may  superinduce  emphysema. 

Certain  occupations  may  entail  certain  diseases :  painters  are 
subject  to  lead  poisoning,  cornetists  to  emphysema;  compositors, 
millers,  and  stonecutters  are  liable  to  acquire  phthisis. 

Certain  noxious  substances  possess  etiological  character :  alco- 
hol induces  cirrhosis  of  the  liver,  or  a  weak  heart,  or  multiple 
neuritis,  or  chronic  nephritis. 

Certain  events  in  the  history  of  a  patient  are  of  diagnostic  value : 
e.g.,  an  haemoptysis  (phthisis),  haematemesis  (gastric  ulcer),  attacks 
of  jaundice  (gall-stones). 

It  is  well  for  the  beginner  to  remember  that  the  taking  of  the 
history  is  often  the  occasion  of  the  first  meeting  between  patient 
and  physician.  To  win  the  confidence  of  the  patient,  the  questions 
should  always  be  asked  in  a  friendly  and  gentle  manner,  and 
modified  to  suit  the  patient  and  the  occasion. 

2.  Condition  of  nutrition  and  strength.  —  The  state  of  a 
patient's  nutrition  is  usually  easily  recognized  by  a  glance 
at  the  face  (fat  or  thin,  of  pale  or  ruddy  color,  bright  or 
sunken  eyes,  lively  or  depressed  expression)  and  the  rest  of 
body  (fat,  muscular  development  of  the  buttocks,  of  the 
arms  and  legs). 

4 


ciFAP.  r       ANAMNESIS   AND   GENERAL   CONDITION  5 

The  state  of  the  nutrition  leads  the  diagnosis  to  a  particu- 
lar group  of  diseases.  A  poorly  nourished  condition  is  indic- 
ative of  the  so-called  cachectic  diseases  (phthisis,  carcinoma, 
leucaemia,  anaemia,  the  severer  form  of  diabetes).  A  patient 
who  maintains  a  well-nourished  condition  in  spite  of  long- 
continued  illness  is  not  a  victim  of  cachectic  disease.  Be- 
cause of  their  short  duration,  the  acute  febrile  diseases  do 
not  essentially  disturb  the  nutrition ;  the  sub-acute  diseases 
(typhoid  fever,  meningitis),  on  the  other  hand,  lead  to  marked 
emaciation. 

The  nutritive  state  is  of  particular  importance  in  the  dif- 
ferential diagnosis  of  the  diseases  of  the  lungs  and  stomach. 
Phthisis  and  carcinoma  of  the  stomach  are  suspected  in 
cachectic  individuals  ;  bronchitis,  ulcer,  and  neurotic  disturb- 
ances of  the  stomach  appear  more  often  in  healthy-looking 
persons. 

o.  Constitution  and  habitus.  —  Through  the  repeated  obser- 
vation of  the  sick,  the  physician  secures  certain  impressions 
of  single  forms  of  disease,  by  means  of  which,  on  seeing 
similar  cases,  he  at  once  suspects  the  nature  of  the  illness. 
These  impressions  are  a  composite  of  the  nutrition,  com- 
plexion, appearance,  position,  speech,  etc.  The  judgment  as 
to  the  habitus  is  of  unquestionable  worth,  but  must  not 
preclude  a  careful  examination. 

Habitus  phthisicus  is  seen  in  tubercular  subjects.  It  is  character- 
ized by  a  pale,  often  spiritual,  countenance,  with  a  fine  skin  and 
circumscribed  redness  of  cheeks ;  the  neck  is  slender,  the  thorax 
weakly  acting.  The  figure  is  thin  and  wasted,  the  hands  are  small 
and  white. 

Habitus  apoplecticus  is  marked  by  a  dark-red,  round,  stoat  face, 
glistening  watery  eyes,  and  short  neck.  The  chest  is  usually 
barrel-shaped,  and  the  respiration  is  of  a  short,  wheezy  character, 
indicative  of  emphysema.  The  body  is  abnormally  fat.  If  the 
patient  is  alcoholic,  he  has  a  tendency  to  apoplectic  insults. 

With  the  habitus  neurasthenicus,  the  patient  is  usually  well 
nourished  and  has  an  expressive  face.  The  eyes  are  bright,  have 
an  unsteady  gaze,  and  are  passive  as  though  their  possessor  were 


6  ANAMNESIS   AND   GENERAL   CONDITION  chap. 

in  suffering.     These  patients  are  moody  and  hypochondriacal,  and 
are  often  suspicious.     Speech  often  impulsive. 

To  recognize  the  habitus  associated  with  a  particular  disease  is 
largely  dependent  upon  experience,  though  it  is  sometimes  an  in- 
tuitive faculty. 

4.  The  position  of  the  patient  in  bed,  which  is  immediately  ob- 
served, may  modify  the  general  impression  as  to  the  character  of 
the  disease.  If  the  patient  is  lying  on  his  back,  it  must  be  observed 
w^hether  he  lies  with  little  muscular  effort  (active  position),  or, 
yielding  to  his  burdens,  he  is  sunk  down  in  bed,  with  knees  drawn 
up  (passive  position).  The  latter  position,  if  maintained,  is  always 
a  sign  of  weakness  or  collapse,  and  is  usually  of  gi-ave  signifi- 
cance. 

A  patient  with  disease  on  one  side  of  the  body  (e.g.,  pneumonia, 
pleurisy,  pneunio-thorax)  often  assumes  a  side  position,  usually 
lying  on  tlie  diseased  side.  In  some  gastric  affections,  the  patient 
lies  on  the  abdomen. 

Restlessness  or  jactitation  is  a  sign  of  fever  (see  below), 
and  is  often  a  forerunner  of  delirium.  At  the  same  time, 
the  danger  of  such  conditions  as  wakefulness  and  stupor 
must  be  regarded. 

The  sitting  posture  is  most  frequently  observed  in  the  dis- 
turbed compensation  of  cardiac  disease,  and  is  a  symptom 
of  dyspnoea  or  orthopnoea. 

5.  The  features,  expression,  and  appearance  of  the  patient 
give  valuable  hints  in  the  determination  of  a  diagnosis. 

The  fades  composita  is  the  intelligent  play  of  features  seen  in 
health.  The  fades  Hippocratica  or  decomposita  is  the  fixed,  dis- 
torted, inanimate  appearance  of  the  features  in  unconsciousness 
and  approaching  death. 

The  physician  should  learn  to  estimate  a  patient's  sen- 
sorium  from  his  facial  expression.  In  the  febrile  diseases 
this  is  of  especial  value  and  importance.  Typhoid  fever, 
meningitis,  and  axjute  miliary  tuberculosis,  sepsis,  for  in- 
stance, run  their  courses  with  disturbed  mental  and  nervous 
functions,  and  the  face  is  then  expressionless,  dull,  and  apa- 
thetic.    The  facial   expression   of   patients  suffering  from 


1  ANAMNESIS    AND    GENERAL   CONDITION  7 

such  diseases  is  very  characteristic  and  may  be  recognized 
at  the  first  glance.  In  other  febrile  diseases,  the  face  has  a 
turgescent  but  a  simultaneously  clear  and  expressive  ap- 
pearance. 

The  beginner  should  learn  thoroughly  the  various  types  of  ex- 
pression ;  the  study  of  the  physiognomy  is  of  unquestionable  diag- 
nostic value,  and  was  highly  regarded  and  constantly  practised  by 
the  physicians  of  bygone  years,  masters  of  observation.  A  careful 
examination  must  not,  of  course,  be  precluded. 

6.  The  complexion  and  the  skin  may  offer  some  help  in 
establishing  a  diagnosis. 

The  normal  pale-red  color  of  the  skin,  with  rosy  cheeks 
and  bright-red  lips,  allows  only  negative  conclusions. 

a.  Flushing  of  the  face,  accompanied  by  heat,  turgescence, 
sweat,  and  bright,  bulging  eyes,  is  usually  a  sign  of  fever. 
Further  symptoms  of  temperature  would,  of  course,  be  looked 
for;  but  one  must  not  forget  the  fleeting  redness  due  to 
excitement  and  modesty. 

h.  Abnormal  paleness  {pallor  eximius),  chalky  or  waxy 
color  of  the  cheeks  and  body,  pallor  of  the  lips  and  conjunc- 
tivae is  a  sign  of  anaemia.  The  ansemia  may  be  primary 
(essential  anaemia)  or  secondary.  It  is  primary  when  de- 
pendent upon  disease  of  the  blood,  as  proven  by  an  exam- 
ination of  the  blood  (Chap.  XI.).  It  is  secondary  w^hen 
it  follows  or  is  coincident  upon  severe  systemic  disease 
(phthisis,  carcinoma,  amyloid  degeneration,  etc.).  The  sud- 
den appearance  of  an  anaemia  which  has  a  continued  duration 
and  which  is  preceded  by  collapse,  speaks  in  favor  of  an  in- 
ternal haemorrhage :  in  the  stomach,  in  the  intestine,  or  in 
the  Fallopian  tube. 

c.  Jaundice  {icterus)  is  a  sign  of  the  deposit  of  bile-pigment 
in  the  skin  and  is  usually  coincident  with  some  form  of  liver 
disease.  A  jaundice  occurring  in  a  w^ell-nourished  patient 
usually  denotes  a  catarrhal  inflammation  of  the  duodenum 
and  bile-ducts  {icterus  simplex).     Jaundice  with  severe  ill- 


8  ANAMNESIS   AND   GENERAL   CONDITION  chap. 

ness  is  indicative,  as  a  rule,  of  grave  affections  of  the  liver 
{icterus  gravis,  Chap.  IV.).  Independent  of  liver  diseases, 
the  graver  form  of  jaundice  may  result  from  toxic  absorp- 
tion, Avhich  destroys  the  red  blood  cells  (cythcemolysis),  as  in 
acute  phosphorus  poisoning,  or  from  the  products  of  the 
acute  infectious  diseases. 

The  yellow  color  of  the  skin  may  be  induced  by  the  administra- 
tion oi picric  acid:  but  then  the  urine  will  not  respond  to  the  tests 
for  bile-pigments. 

The  classification  into  icterus  simplex  and  icterus  gravis  is  of  great 
practical  value.  Of  more  scientific  importance,  however,  is  the 
division  into  jaundice  with  and  without  polycholia.  Icterus  with 
polycholia  is  produced  by  an  overflow  of  bile  in  consequence  of 
great  disturbance  of  the  red  blood  corpuscles.  It  is  comparatively 
rare,  and  leads  rapidly  either  to  death  or  to  recovery  and  is  never 
chronic.  The  stool  is  always  well  colored  with  this  form  of 
jaundice.  Jaundice  without  polycholia  is  caused  by  a  congestion 
in  the  bile-ducts  and  occasions  the  simple  jaundice  and  the  greater 
number  of  cases  of  malignant  jaundice.  In  these  cases  the  stools 
are  usually  colorless,  the  color  varying  with  the  degree  of  occlusion 
of  the  bile-ducts. 

d.  A  bronze-colored  skin  is  the  pathognomonic  symptom 
of  Addison's  disease,  which  has  its  probable  lesions  in  the 
suprarenal  capsules  and  splanchnic  nerves.  It  is  ahvays 
fatal,  and  is  accompanied  by  an  increasing  cachexia.  The 
brown  pigmentation  of  the  mucous  membrane  of  the  mouth 
is  particularly  characteristic. 

e.  Cyanosis  is  the  reddish-blue  condition  of  the  tissues 
seen  in  certain  diseases,  most  easily  recognized  in  the  lips 
and  finger-nails.  It  depends  upon  an  over-charge  of  car- 
bon di'oxide  in  the  blood.  It  may  be  caused  by :  1.  Slow 
or  imperfect  circulation  of  the  blood,  and  it  is,  therefore, 
an  important  symptom  of  uncompensated  cardiac  disease. 
2.  Disturbance  in  the  exchange  of  gases  in  the  lungs  by  (a) 
pulmonary  disease,  or  (b)  abnormal  distention  of  the  abdo- 
men  by  tumors,  meteorism,   or  ascites.     These  conditions 


I  ANAMNESIS  AND   GENERAL   CONDITION  9 

lead  to  cyanosis,  as  a  rule,  only  in  the  advanced  stages, 
whereas  at  the  beginning,  or  at  the  height  of  the  disease, 
there  is  frequently  a  vicarious  increase  in  the  force  of  res- 
piration in  the  unaffected  portion  of  lung.  In  pneumonia 
the  appearance  of  cyanosis  is  of  grave  import.  In  acute 
miliary  tuberculosis  there  is  usually  very  pronounced 
cyanosis. 

A  local  cyanosis  arises  from  venous  congestion  by  thrombi  or 
tumors.     In  the  face,  it  may  be  the  result  of  freezing. 

A  combination  of  cyanosis  and  pallor  (livoj-)  is  sometimes  seen 
in  patients  exhausted  by  heart  disease.  Organic  cardiac  disease, 
with  deep  congestion,  not  uncommonly  produces  cyanosis  with 
jaundice,  the  latter  arising  from  congestion  of,  and  absorption 
from,  the  gall-ducts  in  the  congested  liver. 

7.  Dyspnoea  (air-hunger,  impeded  respiration).  —  The  phy- 
sician must  determine  at  once  whether  the  respiration  is 
normal  or  not,  but  should  notice  especially  whether  it  is 
free  or  labored. 

It  is  essential  to  differentiate  between  increased  and  labored  res- 
pirations. A  simple  increase  in  the  number  of  respirations,  above 
24  to  the  minute,  is  of  no  particular  diagnostic  value,  and  can 
appear  after  bodily  exertion,  as  a  result  of  emotional  influences,  in 
hysteria  or  in  fever. 

Dyspnoea  is  an  indication  of  the  need  of  oxygen.  It  is 
characterized  by  rapidity  and  deepening  of  the  respiratory 
movements,  with  contractions  of  the  auxiliary  muscles  of 
respiration.  The  patient  feels  "  air-hungry "  up  to  the 
point  of  suffocation.  True  dyspnoea  is  usually  accompanied 
by  cyanosis,  a  condition  pathognomonic  of  uncompensated 
heart  disease  and  advanced  disease  of  the  lungs.  Less 
commonly  they  appear  together  in  some  abdominal  diseases 
which  impede  diapragmatic  movement. 

Attacks  of  clysjmoexi  which  pass  away  more  or  less  rapidl3^ 
and  are  followed  by  longer  or  shorter  periods  of  quiet 
breathing,  are  called  asthmatic  attacks. 


10  ANAMNESIS   AND   GENERAL   CONDITION  chap. 

In  Cheyne-Stokes  respiration,  the  respiratory  movements  gradu- 
ally decrease  both  in  extent  and  rapidity  until  they  cease  alto- 
gether, and  a  condition  of  apncea  ensues.  This  is  followed  by  a 
feeble  respiration,  succeeded  in  turn  by  a  somewhat  stronger  one. 
The  amplitude  of  the  respiratory  movements  increases  and  wanes 
again  in  a  similar  manner.  This  phenomenon  is  seen  especially  in 
uraemia,  also  in  cardiac  and  brain  diseases,  and  is  usually  of  grave 
significance.  Still,  an  indication  of  the  Cheyne-Stokes  phenome- 
non is  sometimes  seen  in  the  sleep  of  healthy  persons. 

The  description  of  other  changes  in  respiration  is  reserved  for 
the  chapter  devoted  to  the  subject  (p.  121). 

8.  The  excessive  accumulation  of  lymph  in  the  subcuta- 
neous connective  tissues  is  know^n  as  oedema  or  dropsy.  The 
skin  above  a  dropsical  part  of  the  body  remains  pitted  after 
pressure  by  the  finger.  CEdema  is  such  a  striking  symptom 
that  patients  frequently  make  it  their  principal  complaint ; 
stui)id  patients  may  overlook  it,  however,  and  it  is  a  good 
practice  to  accustom  oneself  to  look  for  it. 

The  first  signs  of  oedema  can  be  recognized  by  pressure 
of  the  fingers  in  the  neighborhood  of  the  ankles. 

The  presence  or  absence  of  oedema  determines  the  ]3ath 
of  the  diagnosis.  If  there  are  no  complicating  cyanosis 
and  dyspnoea  pointing  to  heart  disease,  the  nutritive  condi- 
tion and  the  condition  of  the  blood  must  be  considered  and 
the  urine  must  be  examined  for  albumin. 

a.  Dropsy  imth  cyanosis  and  dyspnoßa  is  the  symptom 
of  uncompensated  heart  disease  :  cardiac  dropsy. 

The  diseases  of  the  heart  interfere  in  a  marked  degree  with  the 
venous  return  of  the  blood.  The  blood  remains  too  long  in  the 
tissues,  where  it  loses  its  O  and  takes  up  more  COg  than  ordinary. 
The  over-distended  veins  no  longer  take  up  the  lymph  in  the  usual 
quantity,  and  the  latter  fluid  floods  the  tissues. 

b.  Dropsy  icith  albumimiria  is  the  symptom  of  disturbed 
function  of  the  kidneys,  and  is  known  as  renal  dropsy. 
Richard  Bright  (1825),  an  English  physician,  first  described 
this  combination  of  symptoms,  and  it  is  therefore  called 
"  Hright's  disease." 


I  ANAMNESIS   AND   GENERAL   CONDITION  11 

The  dropsy  in  albuminuria  may  be  explained  as  follows :  Nor- 
mally, the  capillaries  are  impermeable  to  large  quantities  of  plasma 
on  -account  of  the  vital  activity  of  the  cells  in  their  walls.  This 
activity  is  intact  only  when  the  cells  are  well  nourished,  i.e.,  when 
the  composition  of  the  blood  is  normal.  The  blood  becomes  dete- 
riorated when  the  kidneys  are  diseased ;  in  health,  these  organs 
separate  all  waste  products  from  the  blood;  in  disease  of  the  renal 
epithelium,  metabolic  products  remain  in  the  blood,  the  walls  of 
the  capillaries  become  permeable  because  of  poor  nutrition,  and 
oedema  results.  At  the  same  time,  all  diseases  of  the  renal  epithe- 
lium lead  to  the  appearance  of  albumin  in  the  urine. 

Another  theory  attributes  renal  oedema  mainly  to  an  inflamma- 
tory process  evoked  by  the  action  of  the  same  noxious  materials 
upon  the  walls  of  the  capillaries  as  induces  a  similar  process  in 
the  kidneys. 

In  oedema  due  to  great  congestion,  there  is  often  albuminuria 
because  of  the  simultaneous  congestion  of  the  renal  veins.  The 
diagnosis  is  turned  toward  the  heart  by  the  accompanying  cyanosis 
and  dyspnoea. 

In  chronic  diffuse  nephritis  with  or  without  exudation  and  with 
the  atrophic  kidney  with  granular  degeneration  there  is  frequently 
a  hypertrophy  of  the  left  ventricle  of  the  heart.  The  heart  and 
the  kidney  both  give  symptoms. 

c.  (Edema  accompanying  cachexia  can  be  observed  in 
all  conditions  of  bad  nutrition,  especially  in  the  cachectic 
diseases:  carcinoma,  pernicious  anaemia,  phthisis,  diabetes. 
It  can  appear  temporarily  after  excessive  exertion  and  in 
inanition. 

Under  these  conditions,  the  oedema  can  also  be  explained  by  the 
abnormal  condition  of  the  blood,  the  consequent  disturbance  of 
the  intima,  and  the  permeability  of  its  cells.  The  impoverishment 
of  the  blood  arises  from  disease  of  the  blood  (anaemia,  severe 
chlorosis,  leucaemia),  or  from  ill-nutrition  or  from  chronic  oi'ganic 
disease.  The  transitory  oedema  of  young  people  who  have  exces- 
sively exercised  may  be  partly  explained  by  their  prolonged 
upright  position. 

9.  Exanthemata  (eruptions).  —  The  examination  of  the 
skin  is  incomplete  unless  eruptions  are  searched  for.  These 
are  of  particular  importance  in  the  febrile  diseases  in  which 


12  ANAMNESIS   AND   GENERAL   CONDITION  chap. 

tliey  sometimes  determine  the  diagnosis.  It  is  difficult  to 
recognize  the  various  eruptions  from  description  alone.  The 
student  should  therefore  improve  every  opportunity"  to 
observe  them. 

The  eruption  of  measles  is  scattered  and  is  composed  of  large 
macules ;  that  of  scarlatina,  small  macules,  lying  closely  together 
so  that  it  gives  an  appearance  of  diffuse  redness.  In  typhoid  fever 
there  is  a  roseola,  sparse  over  the  abdomen,  less  thickly  scattered 
over  the  chest,  which  may  vary  in  size  from  the  head  of  a  pin  to  a 
pea.  In  typhus,  a  profuse  roseola.  Exanthemata  may  appear 
sometimes  only  several  days  after  the  beginning  of  the  fever:  the 
absence  of  the  eruption  does  not,  therefore,  exclude  the  diagnosis 
of  an  exanthematous  disease. 

Exanthemata  without  fever,  with  little  or  no  general  disturb- 
ance, may  be  referred  to  diseases  of  the  skin  often  dependent  on 
syphilis. 

Occasionally  eruptions  follow  the  exhibition  of  certain  drugs, 
such  as  the  measles-like  eruption  of  antipyrin  and  the  acne  of 
potassium  iodide.  These  disappear,  naturally,  after  the  cessation 
of  the  medication. 

Subcutaneous  hcemorrhayes  (ecchymoses,  suggillations,  or  petechias 
when  punctate)  occur  at  times :  (1)  in  severe  forms  of  some  of  the 
acute  infectious  diseases,  as  scarlatina,  small-pox,  typhoid,  typhus, 
hasmorrhagic  measles ;  (2)  in  acute  articular  rheumatism*,  even  in 
cases  not  particularly  severe,  peliosis,  and  purpura  rheumatica; 
(3)  in  very  severe  angemia  or  leucaemia ;  (4)  in  some  diseases  of 
the  liver,  as  acute  yellow  atrophy,  rarely  in  cirrhosis ;  (5)  in  cer- 
tain diseases  due  to  disturbed  metabolism,  which  lead  to  great 
weakness  :  morbus  maculosus  Werlhoffi,  scurvy.  In  the  last  named 
disease,  bleeding  from  the  gums  is  characteristic. 

Petechise,  which  become  pustular,  are  symptomatic  of  embolism 
in  the  skin  in  severe  py?emia,  ulcerative  endocarditis,  and  glanders. 

10.  Temperature  of  the  skin.  —  The  body  temperature  can 
be  approximately  estimated  by  the  hand  placed  first  on  the 
chest  and  then  gently  pushed  into  the  axilla.  Elevated 
body  temperature  is  the  principal  symptom  of  fever.  If 
the  temperature  is  above  98.4°  F.  (37°  C),  a  differential 
diagnosis  of  the  febrile  diseases  must  be  made.  See  Chap- 
ter II. 


r  ANAMNESIS    AND   GENERAL    CONDITION  13 

The  most  striking  symptom,  as  a  rule,  to  call  attention  to  a 
febrile  condition,  is  the  flushed  face.  While  the  temperature  is 
being  taken,  the  pulse  should  be  felt,  and  search  for  an  eruption 
should  be  made. 

If  the  patient  is  perspiring  or  the  hand  of  the  physician  is  cold, 
estimation  of  body  temperature  by  the  hand  is  unreliable. 

11.  Dryness  of  the  skin  and  perspiration  can  either  one  be  of 
diagnostic  value.  Great  dryness  is  present  in  conditions  in  which 
there  is  a  large  amount  of  watery  excretion,  such  as  polyuria  from 
any  cause,  diabetes  mellitus,  cholera,  severe  diarrhoea.  Perspira- 
tion, also,  may  be  of  diagnostic  importance.  In  some  of  the  febrile 
diseases  profuse  sweating  may  indicate  the  approaching  crisis. 
In  chronic  diseases  it  may  be  a  sign  of  weakness,  as  in  the  night- 
sweats  of  phthisis.  It  often  accompanies  collapse  and  approach- 
ing death.  Among  drugs,  the  antipyretics  of  the  coal-tar  series, 
especially,  occasionally  produce  profuse  sweating.  It  may  appear, 
however,  now  and  then,  in  healthy  persons,  especially  in  the  young, 
after  a  large  ingestion  of  fluids. 

12.  The  pulse.  —  By  long-establislied  precedent,  the  ex- 
amination of  the  patient  is  begun  by  feeling  of  his  pulse. 
By  this  procedure  one  can  recognize :  a.  The  presence  or 
absence  of  fever.  As  a  rule,  the  pulse-rate  is  quickened 
(over  90)  in  the  febrile  state ;  the  tension  is  increased  while 
the  artery  remains  soft.  b.  The  patient's  general  condition. 
A  strong,  healthy  man  has  a  full  pulse  of  good  tension ;  a 
person  weakened  by  disease  has  a  rap)id,  small  pulse,  with 
little  tension,  c.  The  presence  of  particular  changes  in  the 
heart,  or  in  certain  other  organs  (Chap.  VII.). 

The  pulse  is  felt  by  placing  the  finger  (usually  the  index  finger, 
never  the  thumb)  upon  the  radial  artery,  a  little  above  the  wrist. 
The  hand  of  the  patient  should  not  be  raised  from  the  bed.  The 
beginner  should  accustom  himself  to  count  the  pulse,  watch  in 
hand,  for  a  quarter  of  a  minute,  and  to  determine  the  minute-rate 
from  this  calculation. 

The  feeling  of  the  pulse  is  an  art  which  can  be  learned  only  by 
constant  and  by  long  practice.  Experienced  physicians  sometimes 
bring  it  to  an  extraordinary  degree  of  perfection.  Indeed,  some  of 
the  most  valuable  diagnostic  hints  may  be  gained  by  this  proced- 


14  ANAMNESIS    AND    GENERAL   CONDITION  chap. 

lire.  The  older  physicians,  who  were  masters  of  observation, 
were  accustomed  to  lay  the  greatest  importance  upon  this  prac- 
tice. 

13.  Striking  symptoms.  —  As  a  training  in  diagnostics,  it  is  a 
good  practice  for  the  physician,  after  the  completed  general  exam- 
ination, to  ask  himself  if  he  has  omitted  to  take  note  of  any  strik- 
ing symptom  or  symptoms.  It  is,  of  course,  a  matter  of  experience 
to  observe  and  appreciate  certain  signs  and  symptoms  which  might 
easily  be  overlooked  in  the  general  examination,  and  would  come 
to  light  only  in  the  systematic  examination  of  each  organ. 

Any  single  element  in  a  patient's  complex  of  symptoms 
may  appear  as  a  striking  symptom,  as,  for  instance,  extreme 
pallor,  dyspnoea  and  cyanosis  or  oedema.  Certain  diseases 
may  produce  striking  symptoms,  the  observation  of  which 
may  be  the  starting-point  of  the  diagnosis;  e.g.,  ascites  (fluid 
in  the  abdominal  cavity),  meteorism  (distention  of  the  abdo- 
men through  gas  in  the  intestines),  enlarged  glands,  varicose 
veins,  vomiting,  peculiarities  in  the  urine  or  sputum,  etc.,  etc. 

Mention  must  be  made  of  a  few  striking  symptoms  which 
are  of  more  value  as  to  the  judgment  of  the  present  condi- 
tion of  a  patient  than  for  the  establishment  of  a  differential 
diagnosis. 

1.  A  sudden  change  in  the  condition  of  a  patient,  charac- 
terized by  a  small  and  frequent  pulse,  great  difficulty  in 
respiration,  extreme  pallor,  coldness  of  the  extremities,  nose, 
and  ears,  with  a  rapid  decline  of  the  body  temperature,  is 
known  as  collapse.  It  is  caused  either  by  an  internal  hsemor- 
rhage  or  by  sudden  heart  failure  in  the  crisis,  recurrence, 
or  even  convalescence  of  the  febrile  diseases.  In  the  last 
stage  of  t^qjhoid  fever  and  after  diphtheria,  collapse  must 
be  looked  for.  It  sometimes  follows  a  rapid  sitting  up  in 
bed,  too  early  or  too  long  absence  from  bed,  or  over-great 
exertion  at  stool ;  sometimes  it  appears  without  any  appre- 
ciable cause. 

2.  An  accumulation  of  fluids  in  the  larger  air-passages, 
Avhich  gives  rise  to  the  well-known  stertor  or  death-rattle, 


1  ANAMNESIS  AND   GENERAL  CONDITION  15 

is  a  symptom  of  approaching  death.  It  can  be  heard  at 
inspiration  and  expiration,  and  at  some  distance. 

3.  What  is  commonly  called  the  death-struggle  or  agony 
is  the  appearance  of  the  progressive  and  complete  paralysis 
of  all  muscular  and  nervous  functions.  It  is  characterized 
by  unconsciousness,  the  facies  Hippocratica,  and  the  phe- 
nomenon of  the  death-rattle. 

The  certain  signs  of  death  are :  cessation  of  respiration, 
of  the  sounds  of  the  heart,  of  the  pulse;  absence  of  all 
reflexes,  particularly  that  of  the  cornea. 

It  is  certainly  of  rare  occurrence  that  a  physician  is  in  doubt 
whether  a  seeming  corpse  is  really  dead.  Should  such  a  suspicion 
arise  in  the  case  of  a  sudden  death,  certain  experiments  will  readily 
decide  the  matter;  such  as,  the  exposure  and  incision  of  an  artery, 
electric  stimulation  of  the  muscles,  or  the  insertion  of  a  needle 
into  the  heart,  application  of  down  to  the  lips. 


CHAPTER  II 

THE  DIAGNOSIS  OF  THE  ACUTE  FEBRILE  AND  ACUTE 
INFECTIOUS  DISEASES 

In  addition  to  the  general  considerations,  the  history,  in  a  feb- 
rile case,  must  embrace  :  previous  infectious  diseases  (typhoid  fever, 
measles,  and  scarlatina  attack  an  individual  but  once,  as  a  rule, 
but  pneumonia,  erysipelas,  and  articular  rheumatism  may  occur 
repeatedly)  ;  direct  causes  of  infection,  such  as  similar  illness  in  the 
neighborhood,  or  exceptional  opportunity  for  infection  by  food, 
water,  etc. ;  predisposing  causes  (cold,  emotion,  trauma,  errors  of 
diet);  initial  symptoms:  chill,  headache,  lassitude,  sore  throat, 
vomiting,  pain  in  side  or  back,  etc. 

The  febrile  diseases  in  general  can  be  recognized  by  tlie 
symptom  complex  of  fever.  This  is  characterized  by  a  red, 
flushed  face  often  covered  with  perspiration;  quickened 
breathing ;  full,  rapid,  but  soft  pulse ;  pronounced  thirst ; 
diminished  appetite ;  diminished  quantity  of  urine  of  high 
specific  gravity  and  dark-colored;  increased  body  tempera- 
ture. 

The  temperature  should  be  taken  at  once  with  the  clinical 
thermometer.  The  thermometer  should  remain  in  the  axilla 
10  minutes,  in  the  rectum  5  minutes. 

The  temperature  in  the  mouth  is  from  0.2°  to  0.3°  higher  than 
in  the  axilla ;  the  temperature  taken  in  the  rectum  is  about  1°  F. 
(0.5°-0.8°  C.)  higher  than  that  in  the  mouth.  The  temperature  of 
a  healthy  person  estimated  in  the  mouth  or  rectum  varies  between 
98.5°  and  99.5°  F.  (36.9°-37.4°  C).  It  is  lowest  in  the  morning, 
and  tends  to  rise  in  the  evening  from  0.5°  to  1°  F.  or  C.  The  Ger- 
mans employ  the  scale  of  Celsius,  the  French  that  of  Reamur, 
the  Americans  and  English  the  Fahrenheit  scale.  The  equivalent 
table  is  here  given:  — 

IG 


CHAP.  II 

FEB\ 

tilLJ 

l:  1 

\.ND 

INFK( 

JT 

1Ü 

UIS   D 

ISl 

i:a!ses 

n° 

C. 

=  -t 

n°  R.  = 

9 
5 

n° 

+  32° 

F. 

C. 

K. 

r. 

36° 

= 

28.5° 

= 

96.8° 

37° 

z= 

29.6° 

= 

98.6° 

38° 

= 

30.4° 

:z: 

100.4° 

39° 

= 

31.2° 

=z 

102.2° 

40° 

rz: 

32° 

= 

104° 

41° 

= 

32.8° 

= 

105.8° 

17 


The  so-called  self-registering  thermometers  may  be  recommended. 
After  the  taking  of  the  temperature,  a  little  metal  rod  lying  above 
the  mercury  shows  the  degree  of  fever  until  shaken  down. 

The  minute  thermometers  are  handy  for  general  use.  Because  of 
their  smallness  and  of  a  peculiar  amalgam  of  mercury,  they  give 
the  accurate  axillary  temperature  in  two  minutes. 

The  temperature  of  healthy  persons  in  the  axilla  is  from  36.5° 
to  37.5°  C.  It  is  lowest  in  the  morning,  in  the  evening  from  0.5° 
to  1.0°  higher.  Slight  elevations  of  temperature  appear  transitorily 
after  a  heavy  meal  (digestive  fever),  great  exertions,  continued 
exposure  to  the  sun  (insolation),  warm  baths.  Continued  eleva- 
tion of  temperature  is  a  sign  of  fever.  Temperature  below  36°  C. 
is  called  collapse  temperature;  36°  to  37°  C.  normal;  37.5°  to 
38.0°  C.  subfebrile  temperature;  38°  to  38.5°  C.  light  fever;  38.5° 
to  39.5°  C.  (evenings),  moderate  fever ;  39.5°  to  40.5°  C,  high  fever ; 
above  41.5°  C,  hyperpyretic  temperatures. 

When  fever  exists,  the  temperature  varies  during  the  day ;  in 
the  morning  there  is  a  moderate  decrease  (remission'),  in  the  even- 
ing an  increase  {exacerbation').  If  the  exacerbation  comes  in  the 
morning,  the  remission  in  the  evening,  an  inverted  type  of  fever  is 
present  (most  frequently  in  phthisis). 

Chills :  If  the  bodily  temperature  rises  very  suddenly  while  the 
radiation  of  heat  is  diminished  by  contraction  of  the  cutaneous 
vessels,  the  patient  has  the  sensation  of  intense  cold  which  mani- 
fests itself  in  involuntary  shivering,  chattering  of  the  teeth,  shaking 
of  the  entire  body.  A  chill  appears :  1.  in  a  single  attack  at  the 
beginning  of  the  acute  infectious  diseases  (pneumonia,  erysipelas, 
scarlatina,  etc.) ;  2.  in  repeated  attacks :  (a)  at  regular  intervals : 
in  malaria  (which  may  be  suppressed  by  quinine),  (b)  at  irregular 
intervals  (uninfluenced  by  quinine),  in  the  presence  of  deep  ab- 
scesses and  pygemia,  more  rarely  tuberculosis  and  endocarditis.  — 
Chills  in  the  course  of  a  typhoid  fever  may  indicate  a  relapse  or 
one  of  many  threatening  complications,  as  intestinal  haemorrhage, 


18  FEBRILE   AND   INFECTIOUS   DISEASES  chap. 

perforation,  venous  thrombosis,  emboli  of  the  lung,  etc.,  although 
they  may  he  loithout  any  significance,  probably  through  irritation  of 
the  intestinal  ulcer. 

For  the  especial  diagnosis  of  the  febrile  diseases,  it  is 
necessary  to  recognize  the  type  and  the  course  of  the  fever ; 
for  this  purpose,  during  the  entire  time  of  the  presence  of 
fever,  the  temperature  is  taken  at  regular  intervals  and 
arranged  on  a  fever  chart  (see  below) ;  by  this  means  the 
fever  curve  is  obtained.  Many  of  the  acute  febrile  diseases 
have  characteristic  curves. 

The  type  of  the  fever  is  ascertained  by  the  differences 
between  the  morning  and  evening  temperatures.^  These 
may  be :  continuous  fever  in  which  the  day's  difference  is 
not  more  than  1°;  remittent  fever,  with  a  daily  difference 
of  more  than  1°;  intermittent  fever,  in  which  the  fever  lasts 
only  a  few  hours,  with  an  absence  of  fever  during  the  rest 
of  the  day  (attack  of  fever  and  interval  of  freedom  from 
fever). 

In  the  course  of  almost  all  the  febrile  diseases,  three 
stages  may  be  distinguished :  the  time  during  which  the 
temperature  continues  to  rise  (stadium  incrementi) ;  the 
fastigium,  or  acme,  the  period  of  little  change  in  the  tem- 
perature, which  is  usually  high ;  defervesceiice  (stadium 
decrementi),  the  period  of  decreasing  temperature.  The 
decrease  may  come  rapidly  in  a  few  hours :  cinsis.  The 
crisis  is  often  heralded  by  a  diminution  of  the  frequency  of 
the  pulse  and  an  outbreak  of  perspiration^;  or  it  may  be 
preceded  by  a  short,  very  high  rise  of  temperature  occasion- 
ally accompanied  by  delirium  (^perturbatio  critica) ;  not 
rarely  the  crisis  is  followed  by  (epicritical)  delirium ;  some- 
times collapse  ensues.  The  slow  decrease  of  fever  extending 
over  days  is  known  as  lysis. 

1  In  practice,  the  difference  between  the  highest  and  lowest  tempera- 
tures taken  on  the  same  day ;  the  temperature  is  usually  taken,  for  one 
reason  or  another,  more  than  twice  daily. 

2  The  sweat  of  the  crisis  is  frequently  of  peculiar,  not  disagreeable,  odor. 


II  FEBRILE   AND    INFECTIOUS   DISEASES  19 

T]ie  course  of  the  acute  infectious  diseases,  especially  those 
characterized  by  exanthemata,  is  divided  as  follows:  (1)  stage  of 
incuhation:  from  the  time  of  contagion  to  the  beginning  of  the 
phenomena  of  the  disease ;  (2)  prodromal  stage :  from  the  beginning 
of  the  fever  to  the  breaking  out  of  the  eruption  ;  (3)  eruptive  stage ; 
(4)  stage  of  desquamation  or  defervescence. 

Tlie  character  of  the  fever.  In  severe  fever,  febris  stupida 
and  febris  versatiUs  are  distinguished.  The  former  is 
marked  by  apathy,  a  dull,  listless  countenance,  absolute 
quiet;  the  latter  by  an  anxious  expression,  jactation,  a 
mild  delirium,  picking  at  the  bed-clothes.  The  transition 
from  the  former  to  the  latter  state  is  of  evil  significance. 

Pathognomonic  symptojns.  After  the  reading  of  the  tem- 
perature, or  after  the  recognition  of  the  fever  curve,  other 
quickly  appreciable  signs  which  aid  in  establishing  a  diag- 
nosis must  be  looked  for.  It  is  well  to  accustom  oneself  to 
a  certain  routine.  (It  is  best  first  to  inspect  the  face  and 
skin,  then  the  other  organs  from  above  downward.) 

1.  Exanthemata.  Characteristic  eruptions  appear  in 
measles,  scarlatina,  typhoid  fever,  typhus  fever,  variola, 
varicella,  erysipelas.  The  eruption  decides  the  diagnosis. 
The  exanthemata  do  not  always  appear  at  the  beginning  of 
the  fever  and  often  disapj^ear  before  the  fever,  so  that  their 
aid  must  sometimes  be  foregone. 

2.  Involvement  of  the  sensorium.  Deep  apathy  is  charac- 
teristic of  typhoid,  meningitis,  miliary  tuberculosis,  severe 
forms  of  sepsis,  and  ulcera,tive  endocarditis.  Delirium  is  of 
no  value  for  the  purposes  of  differential  diagnosis. 

3.  Herpes  labialis  and  nasalis  (small  blebs  with  serous  contents, 
at  angle  of  the  mouth  and  on  the  nose,  which  soon  dry  up  and 
leave  a  brownish  crust).  Herpes  is  very  common  in  epidemic 
meningitis  and  pneumonia,  and  speaks  against  tuberculosis,  ty- 
phoid, and  pleurisy. 

4.  Frequency  of  the  pulse  under  certain  circumstances 
may  be  of  great  diagnostic  importance.     Very  slow  at  the 


20  FEBRILE  AND   INFECTIOUS   DISEASES  chap. 

beginning  of  meningitis.  In  scarlatina  unusually  rapid. 
In  typhoid,  aids  in  the  diagnosis  of  the  stage  of  the  disease ; 
in  the  first  stage,  comparatively  slow,  usually  not  over  110 
in  imcomplicated  typhoid ;  in  the  third  stage  usually  from 
100  to  120. 

5.  Involvement  of  other  organs.  Lips:  fuliginous  (sooty 
color)  in  typhoid.  Tongue:  raspberry -like  in  scarlatina, 
coated  in  typhoid.  Neck :  characteristic  affections  in  angina 
and  diphtheria.  Stiffness  of  the  neck  In  meningitis.  Rusty 
sputum  in  pneumonia.  Disteiided  abdomen  painless  to  the 
touch,  in  typhoid ;  retracted  abdomen  in  meningitis.  En- 
largement of  the  spleen  particularly  important  in  typhoid 
and  malaria  (Chap.  IV.).  Diarrhoea  of  characteristic  type 
in  typhoid,  dysentery,  cholera.  Kedness  and  swelling  of 
several  joints  in  acute  articular  rheumatism.  Condition 
of  the  iirine :  diazoreaction  of  the  urine  in  typhoid,  etc. 
Condition  of  the  blood:  in  the  majority  of  the  acute  infec- 
tious diseases  the  number  of  the  white  blood  cells  is  in- 
creased (infectious  hyperleucocytosis) ;  this  is  absent  in 
typhoid,  malaria,  glanders,  and  in  many  cases  of  septi- 
caemia. 

In  many  cases  it  will  be  possible  to  make  an  early  diag- 
nosis of  the  infectious  disease  present  from  the  recognition 
of  the  type  of  the  fever  and  the  consideration  of  the  general 
and  special  symptoms. 

Yet  it  must  not  be  forgotten  that  several  days'  obser- 
vation is  required  for  an  insight  into  the  course  of  the 
fever  and  that  many  characteristic  symptoms  do  not  de- 
velop until  the  disease  is  well  under  way  {e.g.,  exan- 
themata, enlargement  of  the  spleen,  the  diazoreaction, 
diarrhoea,  etc.).  It  is  often  necessary,  therefore,  judging 
from  the  temperature  and  the  habitus  of  the  patient,  to 
content  oneself  with  the  temporary  diagnosis  "acute  in- 
fectious disease"  and  to  institute  the  necessary  general 
therapeutic   measures    (rest  in   bed,   comfortable  position, 


11 


FEBRILE   AND   INFECTIOUS   DISEASES 


21 


light  bed-clothing,  cool  fluid  diet,  ice-bag  to  the  head, 
diluted  acids,  trained  nursing).  These  therapeutic  direc- 
tions are  independent  of  any  special  diagnosis  for  a  few 
days,  when  it  is  usually  possible  to  make  a  differential 
diagnosis  from  the  developed  symptoms. 


Symptoms  of  the  Acute  Infectious  Diseases 

I.    Acute  Infectious  Diseases  with  Regular  Course  of  Fever 

Measles  {morhilU)  (Fig.  1).  —  Incubation  10  days,  with 
coryza,  cough,  gastric  disturbances.  Prodromata,  2  to  3 
days,  beginning  with  chills  and  high  fever.  On  the  2d  or  3d 
day,  diminished  fever; 
on  the  3d  or  4th  day,  ap-  41  q 
pearance  of  the  measles 


38.0 


36.0 


i^ 

4^w- 

mm 

3=3     Z     Z 

..n^EEH 

i--     - 

iFm 

F. 

105.8 


104 


103.2 


100.4 


98.4 


96.8 


Fig.  1.  —  Fever  Curve  in  Measles. 


eruption,  with  high  tern-    40.o 
perature.     From  the  4th 
to  7th  days,  continuous    39.0 
fever;   on  the  7th  day,* 
crisis,  sometimes    lysis. 
Desquamation  for  about 
14  days,  in  small  scales 
(furfuraceous  desquama- 
tion). 

Further  principal  symp- 
toms :  coryza,  cough,  conjunctivitis,  and  photophobia.  Pulse 
somewhat  accelerated  (in  children  from  140  to  160).  Eare 
but  dangerous  complication :  broncho-pneumonia.  The 
rare  complications  with  diphtheria  and  croup  suggest  a 
grave  prognosis. 

Scarlet  fever  (scarlatina)  (Fig.  2).  —  Incubation,  2  to  24 
days,  usually  without  symptoms ;  prodromata,  1  to  2  days, 
beginning  with  chill  and  high  fever.  On  the  2d  day,  the 
eruption  of  scarlet-red  color,  with  rising  temperature.   From 


22 


FEBRILE   AND   INFECTIOUS   DISEASES 


CHAP. 


41.0 

] 

L 

1 

I 

? 

i 

^ 

5 

( 

5 

r 

{ 

? 

3 

10 

A 

/ 

A 

/ 

/ 

\ 

/^ 

f 

400 

/ 

\ 

f 

A 

1 

r 

1 

1 

39.0 

\  1 

, 

\ 

A 

\ 

^  n 

V 

1 

^ 

\ 

A 

1 1 

\ 

/^ 

^7  0 

/ 

r 

36.0 

-J 

_ 

, 

104 


103.3 


100.4 


i.4 


96.8 


Fig.  2.  —  Fever  Curve  in  Scarlatina. 


the  4th  day,  lysis.  Desquamation,  4  to  14  days;  large  scales 
sometimes  fall  off  (desquamatio  memhranaced).  Sometimes 
r  p_      the  fever  of  scar- 

105.8    latina  is  in  no  way 
typical. 

Further  impor- 
tant symptoms  : 
angina,  raspberry 
tongue,  vomiting 
during  the  prodro- 
mal stage.  Compli- 
cations and  seque- 
ls: acute  nephritis, 
otitis,  more  rarely 
glandular  suppu- 
ration, joint  affections  (usually  benign),  endocarditis. 

Erysipelas  (Fig.  3).  —  Incubation,  1  to  8  days.  Begins  with 
chill  and  high 
fever.  On  the 
1st  and  2d  days, 
redness  and 
swelling  of  the 
skin.  Continu- 
ous fever  during 
the  extension  of 
the  erysipelas. 
The  redness  and 
swelling  fre- 
quently appear 
in  batches,  calling  forth  irregular  remittent  or  intermittent 
fever. 

The  redness  and  swelling  are  often  confined  to  the  face  or  to 
the  hairy  part  of  the  head  {erysipelas  capitis  et  faciei),  but  may- 
extend  to  the  neck  and  trunk.  Erysipelas  may  follow  an  injury 
in  any  part  of  the  body. 


41  0 

] 

I 

2 

3 

4 

5 

B 

7 

8 

9 

10 

11 

■ ' 

t 

A 

/^ 

'\ 

~i 

t^ 

r'' 

s^ 

40  0 

\ 

f 

V 

/ 

A 

/ 

> 

/ 

V 

/ 

\ 

^ 

V 

f 

\ 

J 

/ 

39  0 

/ 

1 

f 

\ 

A 

\ 

V 

38.0 

J 

/ 

1 

A 

/ 

\j 

\ 

/ 

V 

I 

37.0 

1 

\ 

A 

/ 

T 

7" 

s? 

V 

. 

F. 

105.8 


104. 


103.3 


100.4 


98.4 


96.8 


Fig.  3.  —  Fever  Curve  in  Erysipelas. 


II 


FEBRILE   AND   INFECTIOUS    DISEASES 


23 


1       2      3 


Croupous  pneumonia  (Figs.  4  and  5).  —  Begins  with  chill, 
high  fever,  and  pain  in  one  side  of  the  chest.  Continuous 
fever.  Crisis  between  the 
od  and  the  11th  days,  often 
on  an  odd  day  of  the  dis- 
ease, most  frequently  on 
the  oth  and  7th.  Crisis 
on  the  3d  day  deceptive 
(Fig.  5) ;  usually  followed 
by  renewed  continuous  fe- 
ver. Sometimes  the  crisis 
is  extended  over  several 
days  (protracted  crisis). 

Pathognomonic  sign  :  rusty 
sputum,    although    some   pa- 
tients with  pneumonia  have  no  expectoration,  or  a  whitish- 
yellow  sputum  which  is  not  characteristic. 

Enlargement  of  the  spleen,  which  does  not  disappear  until 
complete  resolution  has  taken  place. 


105.8 


102.2 


c. 

41.0 


40.Ü 


39.0 


38.0 


37.0 


36.0 

Fig.  4.  —  Fever   Curve    in   P>-eumo- 
NiA.     Crisis  4th  to  5th  Dat. 


— i — 

■^ r 

1 

1 

\ 

1 
1 

t 

1 

1 

i 

1 

i 
i 

F. 

105.8 


104 


102.2 


100.4 


98.4 


96.8 


36.0 


100.4 


98.4 


J  96.8 


Fig.  5.  —  Fever  Curve  in  Pxeumoxia.     Pseudoceisis  on  the  3d, 
Crisis  ox  the  11th  Dat. 

A  new  rise  of  temperature,  indicating  an  advancing  infiltration, 
may  follow  the  crisis.  This  is  called  pseudocrisis.  This  is  to  be 
diagnosticated,  when  in  spite  of  the  fall  of  temperature,  the  pulse 


24 


FEBRILE   AND   INFECTIOUS   DISEASES 


CHAP. 


and  rapidity  of  the  respiration  remain  abnormally  high;  or  when, 
despite  the  normal  temperature,  the  hyperleucocytosis  persists. 

Physical  signs  of  the  infiltrated  lung  at  the  height  of  the 
disease :  dulness  (with  a  tympanitic  note)  and  bronchial 
breathing  (cf.  Chap.  VI.). 

If  a  regular  crisis  does  not  supervene,  or  if  the  fever  rises 
irregularly  after  the  crisis,  it  is  to  be  referred  to  a  pleurisy 
(serous  or  purulent),  more  rarely  gangrene,  tuberculosis,  or 
abscess  of  the  lung. 

Typhoid  fever  (Fig.  6).  —  Incubation  7  to  21  days.  Pro- 
dromata  for  about  a  week,  with  indefinite   symptoms   of 


36.0 


1  96.8 


Fig.  6.  —  Schematic  Fever  Curve  in  Typhoid  Fever. 


general  lassitude.  Stadium  incrementi,  terrace-like  rise  of 
temperature  of  remittent  character  as  it  ascends.  Acme 
reached  on  4th  to  7th  day.  Fastigium,  continuous  fever. 
Defervescence,  fever  remitting  as  it  descends.  Morning 
temperatures  sink  daily ;  during  the  first  days  the  evening 
temperatures  reach  a  high  point  (uncertain  stage,  steep 
fever  curve). — The  duration  of  the  2d  stage  varies  with 
the  severity  of  the  disease.  In  light  cases  the  descending 
remission  of  the  fever  may  begin  on  the  16th  or  14th  days 
or  even  earlier;  in  very  severe  cases  the  continuous  fever 
may  last  until  the  5th  week. 

Further  2')rincipal  symptoms:  apathy,  stupor,  fuliginous, 
furred  tongue.  Koseola  from  the  end  of  the  1st  to  the  middle 
of  the  2d  week.      Enlargement   of  the  spleen  during  the 


II 


FEBRILE    AND   INFECTIOUS   DISEASES 


25 


acme.  Meteorisni.  Stools,  diarrhoeal  of  pea-soup  consist- 
ency. Diazoreaction  in  the  urine,  no  hyperleucocytosis. 
Frequently,  bronchitis. 

The  diagnosis  is  made  by  the  presence  of  several  of  these  signs 
at  the  same  time ;  it  is  scarcely  possible  to  do  so  from  any  single 
one.  Many  symptoms  may  be  absent ;  for  instance,  decided  meteor- 
ism,  the  diazoreaction,  the  diarrhoea. 

The  diagnosis  of  typhoid  must  embrace  the  week  and 
stage  of  the  disease,  if  possible.  This  is  sometimes  facili- 
tated by  complications  which  mark  certain  periods ;  thus, 
intestinal  hcemorrhages  take  place  most  frequently  during 
the  time  of  defervescence  ;  and  during  this  period,  too,  fatal 
perforation  of  the  intestine  sometimes  occurs  (vid.  p.  101). 

The  prognosis  depends,  among  other  things,  upon  the 
frequency  and  tension  of  the  pulse  and  the  degree  of  stupor. 

Typhus  fever  (typhus  exanthematicus,  spotted  fever)  (Fig. 
7).  —  Incubation  3  to  21  days.     No   prodromata.     Begins 


Fig.  T.  —  Fevek  Cuete  in  Typhtjs  Fever. 

with  chill  and  high  temperature.  On  the  3d  day,  a  profuse 
roseola.  Continuous  fever  from  13  to  17  days  with  slight 
remissions  on  the  6th  to  the  8th  day.  Temperature  falls 
by  crisis,  with  delirium. 

The  roseola  soon  becomes  petechial.  Bronchitis.  The 
mental  symptoms  especially  severe. 

Recurrent  fever  (relapsing  fever)  (Fig.  8).  —  incubation 
5  to  7   days.     iSTo  distinct  prodromal   stage.     Begins  with 


26 


FEBRILE   AND   INFECTIOUS   DISEASES 


CHAP. 


chill  and  rapid  rise  of  temperature.    Continuous  fever  5  to  7 
days.    Temperature  falls  by  crisis.    Then  5  to  8  days'  absence 


100.4 


36.0^1 


Fig.  8. — Fevek  Cueve  ln  Kelapölnu  Feveb. 


of  fever;  thereupon  renewed  continuous  fever,  usually  of 
short  duration.  Frequently  after  absence  of  fever  for  7 
days,  continuous  fever  for  from  2  to  3  days.  —  Great  rapid- 
ity of  pulse.  Enlargement  of  the  spleen.  Eoseola.  Herpes. 
SjyirochetiE  Ohermeieri  in  the  blood  during  the  fever  (Chap. 
XII.). 

Variola  (small-pox)  (Fig.  9).  —  Incubation  10  to  13  days. 
The  actual  course  of  the  disease  may  be  divided  into  4 


105.8 


103.3 


36.0 


100.4 


98.4 


96.8 


Fig.  9.  —  Fkvkr  Cikve  in  Variola. 


stages :  fitaga  of  invasion  (])rodroinata),  beginning  with  chill 
and  high  fever,  3  to  4  days.     Stage  of  eruption^  diminished 


11. 


FEBRILE   AND    INFECTIOUS   DISEASES 


27 


100.4 


fever  to  the  9tli  day.  Stage  of  suppuration  (fever  of  pus), 
severe  remittent  fever,  9  to  11  days.  Stage  of  exsiccation 
(drying  up  of  the  papules),  fall  of  the  temperature  by  lysis. 

The  eruption  forms  at  first  red  spots  Avhich  gradually 
change  into  larger  papules.  On  the  6th  day  they  become 
filled  with  a  cloudy  fluid,  on  the  8th  day  they  are  blebs  filled 
with  pus  5  from  the  9tli  day  the  contents  are  poured  out,  and 
the  drying  up  begins  on  the  11th  day.  The  eruption  attacks 
the  mucous  membrane  of  the  mouth  and  throat.  —  Severe 
drawing  pains  in  the  knees 
and  back.  ^  ■  i     2     3     4 

Varioloid  (Fig.  10)  is  the 
mildest  form  of  small-pox 
as  it  is  seen,  after  conta- 
gion, in  persons  who  were 
unsuccessfully  vaccinated  or 
vaccinated  more  than  ten 
years  previously.  In  vario- 
loid, the  period  of  invasion 
is  followed  immediately  by 
the  stage  of  drying  up,  with- 
out the  fever  of  suppura- 
tion. The  eruption  may  be  merely  indicated  or  it  may 
appear  in  some  irregular  form  (erythema). 

Varicella  (cliicken-pox).  —  Fever  begins  with  a  chill  and  is 
continuous  until  the  drying  up  of  the  eruption,  2  to  4  daj^s. 

Eruption  characteristic :  rose-colored,  slightly-elevated 
spots,  which  soon  become  vesicular.  Found  on  the  gums 
and  throat  also.  Seldom  like  variola,  but  then  to  be  dis- 
tinguished by  the  fact  that  in  varicella  all  the  stages  of  the 
eruption  apjjear  simultaneously.  Prognosis  absolutely  good. 
In  very  rare  cases  sequelse  are  seen ;  for  instance,  acute 
nephritis. 

Malaria  (intermittent  fever)  (Figs.  11,  12,  13\  —  Incuba- 
tion, 7  to  21  days.    Ko  distinct  prodromata.    Chill  with  high 


Fetek  CrETE  IN  Varioloid. 


28 


FEBRILE    AND   INFECTIOUS   DISEASES 


CHAP. 


C. 

41.0 


40.0 


39.0 


38.0 


36.0 


1  2 3 

ill'/  11  a  'jli;,  nj  j  1 1  i;U  ä  I 

ipppi 


F. 

105.8 


104 


ioa.2 


100.4 


98.4 


96.8 


Fig.  11. — Fever  Curve  in  Quo- 
tidian Intermittent  Fever. 


elevation  of  temperature ;  in  a 
few  hours,  critical  descent  of 
fever,  with  perspiration,  then 
apyrexia.  Shortly  before  and 
during  the  fever,  the  cause  of 
the  malaria,  the  plasmodium  of 
Laveran,  in  the  blood.  The  at- 
tack is  repeated  at  the  same 
time  of  day  the  following  day 
(quotidian  type).  Fig.  11 ;  or  on 
alternate  days  (tertian  type), 
Fig.  12 ;  or  every  fourth  day 
(quartan  type).  Fig.  13.  If  the 
introductory  chill  ai)pears  before 
or  after  the  regular  time  of  day, 
it  is  spoken  of  as  anticipated  or 
postponed     intermittent     fever. 

Two  attacks   in   one  day  characterize  double  intermittent 

fever. 

The  diagnosis  of  malaria  is  rendered  absolutely  certain 

in  doubtful  cases  by  the  microscopic  demonstration  of  the 

Plasmodium  in  the  blood;    also   by   the   establishment   of 

the  type  of  the  fever,  the 

enlargement  of  the  spleen, 

and    the    specific    control- 
ling action  of  from  1  to  2 

grammes  of  quinine  when 

this  dose  is  administered  6 

hours  before  the  expected 

attack  of  fever. 

In  the  tropics  there  are 

forms  of  malaria  in  which 

the  fever  is  entirely  irreg- 
ular;   at    the     same    time 

organic    affections    appear. 


41.;  ^ 

2      3 

4      5 

6 

7 

40.0   - 

- 

^0  0    .  - 



38.0  - 

- 





-  — 

'^7  0 

A 

/^  / 

A 

.     / 

y 

Z 

V     ^/ 

'V    v* 

\/- 

-^^ 

36.0  ~ 

F. 

105.8 

104 

103.2 

100.4 

98.4 
96.8 


Fi(i.  1'. 


Fkvicii  Curve   in   Tertian    In- 

'IICRMITTENT    FeVEK. 


II 


FEBRILE   AND    INFECTIOUS   DISEASES 


29 


which  totally  obscure  the  picture  of  the  disease  (masked 
intermittent  fever).  The  diagnosis  is  made  certain  only  by 
the  curative  action  of  quinine. 

In  the  temperate  climates,  malarial  neuralgia  is  seen, 
attacks  of  neural  pain  whieli  return  at  certain  times  of  the 
day  like  the  paroxysms  of  fever.  They  are  controlled  by 
quinine  {e.g.,  supraorbital  neuralgia). 

Irregular  fever,  intermittent  in  type,  which  does  not  yield  to 
quinine,  and  in  which  the  malarial  plasmodia  can  not  be  found  in 
the  blood,  is  to  be  referred 
to  deeply  lying  abscesses  or 
endocarditis  or  latent  tuber- 
culosis. 

Influenza :  after  a  short 
prodromal  stage,  sudden, 
usually  high  fever,  which 
lasts  for  several  days  in  con- 
tinuous and  remittent  form, 
accompaniedby  intense  pros- 
tration and  great  pain  in 
the  extremities.  Frequently 
DO  localization,  frequently 
catarrh  of  the  bronchi.  The 
unusually  large  number  of 
complications  or  sequelae  is 
characteristic  :     respiratory 

tract  (catarrhal  and  croupous  pneumonia)  ;  circulatory  apparatus 
(endocarditis,  thrombosis)  ;  nervous  system  (neuralgias  and  psy- 
choses), etc.  The  prognosis  is  good  except  when  complications  or 
sequelse  set  in. 


c. 

41.0 


40.0 


39.0 


38.0 


37.0 


36.0 


1 

2 

3 

1 

5 

G 

7 

8 

Mi 

I  I  1 

III 

Ml 

IM 

III 

Ml 

III 

1 

1 

1 

1 

1 

1 

II 

A 

A 

/ 

\J 

A 

,A 

A 

J 

/ 

\ 

r 

k  / 

,  1 

/ 

/ 

J 

V 

/ 

V 

y 

J 

/ 

F. 

105^ 


104 


102.3 


100.4 


98.4 


96.8 


Fig.  13.  —  Fetee  CrEVE  ix  Quaetax  Ix- 

TEEMITTENT    FeTEE. 


II.     Acute  Infectious  Diseases  without  Regular  Course 

A  number  of  acute  infectious  diseases  run  their  courses 
with  irregular  fever  which  does  not  conform  to  any  type. 
The  diagnosis  of  these  diseases  rests  upon  the  local  lesions. 

Follicular  amygdallitis  {angina  follicularis).  —  Eedness  and 
swelling  of  the  soft  palate,  the  tonsils,  and  the  pharynx, 
often  accompanied  by  a  white  or  grayish  exudate,  which  can 


30  FEBRILE    AND   INFECTIOUS   DISEASES  chap. 

usually  be  removed  without  causing  hsemorrhage.  Strep- 
tococci are  most  often  found  in  the  membrane.  Submax- 
illary glands  frequently  involved.  Fever,  beginning  with 
a  chill,  continuous  for  several  days  or  lightly  remittent. 
General  disturbances  not  very  severe  despite  the  high  tem- 
perature ;  if  severe,  diminished  in  a  few  days.  An  acute 
nephritis  may  appear  after  a  light  attack  of  angina. 

Abscess  of  the  tonsil  sometimes  supervenes  (angina  apostema- 
tosa). 

Diphtheria.  —  Tousils  and  palate  covered  with  a  grayish- 
white  membrane,  the  removal  of  which  produces  bleeding 
from  the  mucous  membrane.  Diphtheria  bacilli  may  be 
obtained  from  this  membrane  by  culture.  In  severe  cases, 
the  membrane  involves  the  nose,  the  larynx,  the  bronchi. 
Enlargement  of  the  submaxillary  glands.  The  profound 
general  disturbance  is  characteristic  (small,  rapid  pulse, 
stupor).  Frequently,  albuminuria.  Fever  throughout  atypi- 
cal, and  gives  no  data  for  the  prognosis,  which  depends  in 
part  upon  the  severity  of  the  local  affection,  in  part  upon 
the  profundity  of  the  general  infection.  Frequent  charac- 
teristic sequelae :  paralysis  of  accommodation,  of  the  palate, 
of  the  extremities.  There  are  cases  of  pharyngeal  inflam- 
mation, in  which  the  diagnosis  between  diphtheria  and 
angina  can  not  be  made  for  some  time;  the  decision  must 
be  reached  by  a  bacteriological  examination  (cf.  Chap, 
XII.). 

Acute  miliary  tuberculosis.  —  Atypical  fever.  Marked 
cyanosis  and  dyspnoea.  Over  extensive  areas  of  the  lungs 
crepitant  rales  without  dulness.  In  the  urine,  diazoreac- 
tion.  In  some  cases  tubercles  in  the  clioroid  may  be  found 
ophthahnoscopically.  Prognosis  very  bad ;  death  in  from  8 
to  14  days. 

Cerebro-spinal  meningitis.  —  Irregular,  partly  remittent, 
partly  continuous  fever,  with  a  long  course  and  many  remis- 


II  FEBRILE   AND   INFECTIOUS   DISEASES  31 

sions.  Deep  stupor.  Pathognomonic  symptom :  stiffness 
of  the  neck.  In  the  early  stages,  hypersesthesia  of  the 
extremities,  slow  pulse. 

The  diagnosis  must  include  the  etiology.  1.  Epidemic  (spo- 
radic) meningitis  is  diagnosticated  by  positive  exclusion  of  other 
causes ;  during  an  epidemic  the  diagnosis  is  easier.  2.  Tubercular 
meningitis  may  be  diagnosticated  in  the  presence  of  tuberculosis 
of  the  lungs,  usually  somewhat  advanced.  Herpes  labialis  never 
present.  Recently  this  diagnosis  has  been  repeatedly  made  by 
finding  tubercle  bacilli  in  the  cerebro-spinal  fluid  obtained  by 
puncture  of  the  cerebro-spinal  canal  (lumbar  puncture  of  Quincke). 
3.  Meningitis  due  to  an  extension  of  an  otitis  media. 

The  stiffness  of  the  neck  is  usually  not  very  distinct  during  the 
first  few  days,  but  is  well  elicited  by  the  end  of  the  first  week.  If 
the  meningitis  advances,  the  stiffness  disappears,  but  the  symp- 
toms of  paralysis  supervene.  A  mild  stiffness  of  the  neck  may  be 
present  at  the  beginning  of  severe  cases  of  pneumonia  and  typhoid ; 
meningitis  may  accompany  these  diseases. 

Acute  articular  rheumatism. — Irregular  remittent  fever. 
E-edness,  swelling,  and  pain  in  several  joints,  usually  affect- 
ing both  sides  of  the  body  symmetrically.  Fever  and  local 
affection  yield  in  two-thirds  of  all  cases  to  salicylic  acid  or 
antipyrin.  Frequent  complications  :  endocarditis,  with  per- 
manent valvular  lesions ;  more  rarely,  pleurisy,  pericardi- 
tis. Atypical  forms  of  articular  rheumatism,  especially  in 
gonorrhoea. 

Parotitis  epidemica  (mumps). — Irregular,  moderately  high 
fever,  lasting  from  2  to  8  days.  Pain,  enlargement  of  one  or 
both  parotids  ;  resolution  usual,  sometimes  suppuration.  In 
a  few  cases,  accompanied  or  followed  by  a  febrile  orchitis, 
more  rarely  epidydimitis. 

Sepsis  (pyaemia,  septicaemia,  blood  poisoning).  —  Atypical, 
usually  remittent  fever,  commonly  with  irregular  chills. 
Stupor,  great  prostration.  Usually  no  hyperleucocytosis. 
Primary  suppuration  often  present,  as,  infected  w^ounds,  in 
the  uterus  (puerperal  sepsis),  in  paronychia  and  phlegmo- 


32  FEBRILE   AND   INFECTIOUS   DISEASES        chap,  ii 

nous  processes,  in  ca%dties  of  the  head  (empyema  of  the 
antrum  of  Highmore,  otitis  media),  in  the  prostate.  The 
entrance  of  the  producers  of  the  process  may  remain  hidden 
(cryptogenetic  septicsemia).  Shortly  before  death  the  re- 
sponsiljle  bacteria  may  be  found  in  the  blood.  Pyemia  is 
characterized  by  localized  abscesses  in  various  organs  of  the 
body,  while  septiccemia  denotes  the  general  toxaemia  without 
localization.  These  two  forms  of  disease  frequently  pass 
over  into  each  other.  In  the  pure  pysemic  type,  hyperleu- 
cocytosis  usually  exists.  Differentiation  between  the  vari- 
ous kinds  of  sepsis  according  to  the  etiology  (streptococci, 
staphylococci,  diplococci,  etc.)  has  no  clinical  value. 

Acute  endocarditis.  —  Irregular,  usually  remittent  fever, 
with  the  physical  signs  of  a  lesion  of  a  cardiac  valve  (intra- 
cardiac murmur ;  the  systolic  murmur  alone  does  not  denote 
an  endocarditis).  The  diagnosis  must  differentiate  between 
endocarditis  of  benign  (verrucous  or  warty)  and  of  malig- 
nant (ulcerative)  character.  The  latter  diagnosis  is  certain 
whq^i  repeated  chills  and  many  cutaneous  emboli  manifest 
themselves.  A  benign  endocarditis  frequently  becomes  ma- 
lignant. An  acute  endocarditis  develops  during  or  after 
other  infectious  diseases.  Endocarditis  following  articular 
rheumatism  is  usually  warty,  and  disappears,  leaving  val- 
vular lesions.  Endocarditis  accompanying  sepsis,  pneumo- 
nia, gonorrhoea,  usually  ulcerative. 


CHAPTER    III 

DIAGNOSIS  OF  THE  DISEASES  OF  THE  NERVOUS  SYSTEM 

The  following  data  are  especially  important  in  the  anamnesis 
and  history  of  nervous  diseases:  (1)  Heredity  in  psychical  dis- 
eases,   neurasthenia,  epilepsy,  hysteria,    S}^hilis   in   the  parents. 

(2)  Previous  disease,  especially  syphilis,  acute  infectious  disease. 

(3)  Causes  and  predisposing  factors  :    trauma,  exposure,  fright, 
intoxications  (lead,  mercury,  alcohol,  excessive  use  of  tobacco). 

The  serial  data  for  registering  the  status  prcesens  are  to  be 
found  on  page  2,  under  B.  I.  The  disturbances  of  sensation 
and  motility  require  special  consideration  (B.  I.  6),  for  which  the 
following  guide  or  scheme  is  in  use  at  the  1st  Medical  Clinic  of 
Berlin :  — 

STATUS  OF  NERVOUS   SYSTEM 

Ä .   Motion 

I.    Position  of  the  limbs  at  rest. 
a.   Abnormalities  in  position. 
h.    Atrophy  ? 

c.   Abnormal     involuntary    movements    (tremor,    convulsive 
movements)  ? 
II.    Movements. 

a.  Free,  active. 

b.  With  resistance,  active. 

c.  Passive. 

1.   Face 

I.    Are  both  halves  symmetrical? 
Equal  palpebral  fissures  ? 
Equal  nostrils  ? 
Mouth,  straight  or  crooked  ? 
Are  the  eyes  normal  or  quiet  ? 
Pupils  equal  ? 

D  33 


34  DISEASES  OF   THE   NERVOUS   SYSTEM  chap. 

II.  Request  the  patient  to  wrinkle  the  forehead,  close  the  eyes, 
pucker  the  mouth,  laugh,  blow  out  the  cheeks,  extrude  the 
tongue,  move  it  to  right  and  left,  move  the  eyes  (to  the 
right,  left,  upwards,  downwards,  and  to  converge). 

2.   Cavity  of  the  Mouth  ;  the  Larynx 

I.    Condition  of  the  soft  palate  and  uvula. 
II.    Elevation  of  the  same  in  phonation. 

3.   Throat  and  Neck 

I.    Position  of  the  head. 

II.  Turn  head  to  right  and  left,  bend  it  forwards  and  backwards 
(oppose  resistance  lastly). 

4.    Shoulders  and  Arms 

I.   Appearance  of  the  scapula,  position  of  the  arms,  of  the  fingers, 
size  of  the  thenar  and  hypothenar  eminences,  condition  of 
interosseous  spaces. 
II.    Elevate  the  shoulders,  raise  the  arms  (to  the  vertical  position), 
abduct  them,  hold  them  horizontally  forwards. 
Flex  and  extend  the  forearm. 
Pronate  and  supinate. 
Flex   and   extend  the  fingers,  spread  them  apart,  close  the 

thumbs  upon  the  palms. 
Force  of  grasp. 

5.   Legs 

I.    Condition  of  the  trochanters. 
n.    Elevation,  abduction  and  adduction. 
Flex  and  extend  the  legs. 
Flex  and  extend  the  feet. 

6.   Trunk 
I.    Breathing  (rhythm)  ? 
Abdomen  (retracted)  ? 
Spinal  column  (shape)  ? 
Buttocks  (hypertrophied  or  atrophied)  ? 
II.    (Only   necessary   if    a    disturbance   is   perceived    during   in- 
spection). 
Bend  trunk  forwards,  backwards,  to  the  sides,  take  deep  in- 
spiration, cough. 


Ill  diseasp:s  of  the  nervous  system  35 

7.  Bladder  and  Rectum  (inquiry) 

8.  Equilibrium  with  closed  eyes 

9.  Gait 

10.  Ability  to  grasp  objects 

11.  Speech 

12.  Chirography 

B.  Sensation 

I.    Subjective  signs :  deafness,  formication,  pain,  etc. 
II.    Objective  examination. 

a.  Sensibility  of  the  skin. 

1.  Most  gentle  contact. 

2.  Painful  pin  pricks. 

3.  Cold. 

4.  Heat. 

b.  Muscular  sense. 

1.   Sensation  of  movement. 

c.  Visual  field. 

d.  Hearing. 

e.  Smell. 
/.   Taste. 

C.  Reflexes 
a.   Skin  reflex. 

Reflex  of  sole  and  palm,  cremaster,  abdominal,  lids,  con- 
junctiva, palate. 
h.   Tendon  and  periosteal  reflex. 

Patella,  tendo  Achillis,  foot  clonus,  wrist,  biceps,  triceps. 
c.   Pupillary  reflex. 

Condition  of  the  sensorium:  dulness,  stupor,  apathy  in 
febrile  diseases  is  an  indication  of  an  intense  infection,  and 
suggests  a  grave  prognosis.  These  mental  states  are  of 
diagnostic  value  in  typhoid,  meningitis,  miliary  tuberculosis, 
sepsis. 

In  nonfebrile  diseases  apathy  and  stupor  are,  as  a  rule, 
the  precursors  of  complete  unconsciousness  {coma,  lethargy). 

Coma  is  present  in  cases  of :  1.  Poisoning ;  in  these  cases 
the  history  will  determine  the  condition,  or,  better,  the  ex- 
amination for  poison  of  the  contents  of  the  stomach  obtained 


36  DISEASES  OF   THE   NERVOUS   SYSTEM  chap. 

by  lavage.  2.  Apoplexy ;  often  recognized  by  the  coinci- 
dent facial  palsy,  or  by  a  hemiplegia ;  the  deeper  and  the 
longer  in  duration  the  coma,  the  worse  the  prognosis. 
3.  In  increased  cerebral  pressure,  for  example,  induced  by 
tumors,  associated  with  choked  disc.  4.  In  the  course  of 
the  diseases  due  to  perverted  or  defective  metabolism, 
especially  diabetes ;  recognized  by  the  deep  and  laborious 
respiration  (intense  breathing  of  Kussmaul).  Usually  lethal 
in  termination.  It  is  seldom  present  in  carcinoma  and 
anaemia.  5.  During  the  course  of  nephritis  (urcemic  coma), 
commonly  preceded  by  repeated  attacks  of  convulsions  and 
high  arterial  tension.  An  important  diagnostic  rule  may 
be  thus  derived :  in  every  case  of  coma  arising  from  an 
unknown  cause,  the  urine  should  be  carefully  drawn  by 
catheter  and  examined  for  both  albumin  and  sugar.  Mark- 
edly rigid  radial  arteries  would  point  to  cerebral  apoplexy. 
In  many  cases  the  diagnosis  will  be  determined  by  the 
history  obtained  from  the  relatives  and  friends. 

Dulness  of  the  sensorium,  ranging  from  slight  apathy  to  stupor, 
is  often  a  sign  of  an  existing  psychosis,  which  could  be  diagnosed 
by  the  presence  of  haUucinations  and  delusions,  but  better  by  the 
exclusion  of  all  the  above-mentioned  visceral  causes  of  coma. 

It  is  especially  important  for  the  diagnostician  to  recognize  the 
psychoses  due  to  certain  drugs  (salicylic  acid,  bromides,  etc.),  to 
chorea,  to  certain  of  the  last  stages  of  heart  affections,  to  all  con- 
ditions of  inanition ;  in  all  these  there  are  illusions  and  hallucinar 
tions  of  hearing  and  sight,  as  well  as  delusions  of  persecution  and 
those  of  a  religious  character. 

Essential  mental  disturbances  (mania,  melancholia,  paranoia, 
paretic  dementia)  in  well-developed  cases  are  readily  recognized, 
and  would  most  likely  be  turned  over  to  asylums  (strict  legal  forms 
being  observed).  Most  frequently  the  first  indistinct  beginning 
of  dulness  of  judgment  or  of  perception  succumbs  to  the  acumen 
of  the  physician. 

To  determine  such  indefinite  psychical  anomalies  (motiveless 
pleasurable  and  painful  feelings,  sudden  change  of  mood,  diminu- 
tion of  intelligence  and  of  memory,  moral  decrepitude)  the  phy- 
sician must  carefully  investigate  whether  the  case  is  one  of  psychic 


Ill  DISEASES   OF   THE    NERVOUS   SYSTEM  37 

reaction  to  a  somatic  functional  disturbance  or  of  a  beginning  in- 
sanity. In  the  latter  case  the  signs  of  an  impending  paralytic 
dementia  ought  to  be  looked  for :  iridoplegia,  inequality  of  the 
pupils,  absence  of  or  increase  of  the  knee  jerk,  disturbances  of 
speech,  etc.  The  further  elucidation  of  this  most  highly  impor- 
tant question  would  be  transferred  to  the  psychiatrist. 

Delirium  in  febrile  diseases  is  conditional  to  the  height  of 
the  fever  and  of  the  intoxication  ;  it  is  without  essential 
prognostic  significance.  It  occurs  frequently  before  the 
crisis  of  the  disease  (^perturhatio  critica),  after  its  crisis 
(delirium  of  defervescence),  and  it  is  often  the  sign  of  col- 
lapse. When  accompanying  non-febrile  affections  (irrespec- 
tive of  the  psychoses  and  intoxications,  especially  alcoholism), 
it  is  always  an  indication  of  intense  exhaustion  (inanition, 
delirium). 

Diffuse  headache  when  transitory  is  usually  of  small  diag- 
nostic importance  (as  in  fever,  over-exertion,  excesses,  dyspep- 
sia, constipation,  female  genital  affections,  etc.).  Paroxysmal 
headache  is  often  confined  to  one  side  of  the  head.  Migraine : 
the  latter  is  chiefly  associated  with  dyspeptic  signs,  and 
often  terminates  in  an  attack  of  vomiting ;  not  infrequently 
is  it  limited  to  the  course  of  distribution  of  certain  nerve 
trunks ;  when  occurring  thus,  painful  points  on  pressure 
may  be  elicited.  Neuralgia:  continuous  headaches  occur  in 
neurasthenia  as  well  as  in  chlorosis,  heart  diseases,  etc. ; 
when  occurring  with  diabetes  it  denotes  a  grave  form  of  the 
disease.  It  is  oflen  the  ßrst  sign  of  a  developing  urcemia.  It 
also  occurs  in  tertiary  syphilis,  and  is  then  especially  noc- 
turnal (dolores  osteocopi). 

Vertigo.  Occurs  frequently  in  gastric  and  intestinal  dis- 
eases. When  present  in  a  heart  affection  it  points  chiefly 
to  a  stenotic  lesion.  It  accompanies  anaemia.  When  con- 
comitant with  shrill  tinnitus  aurium,  it  indicates  an  aural 
disease  (labyrinth),  and  is  known  as  the  Menih-e  symptom. 
It  is  also  present  in  cases  of  cerebral  tumors  and  special 


38 


DISEASES   OF   THE   NERVOUS  SYSTEM 


CHAP. 


affections  of  the  cerebellum.     It  is  not  infrequently  associ- 
ated with  imperative  movements. 


Anatomical  Introduction 

An  intimate  knowledge  of  the  anatomy  of  the  central  nervous 
system  is  essential  in  order  to  form  a  correct  diagnosis  of  the 
various  forms  of  disease  of  the  nervous  system. 


^  E  a 


d  , 


-fuz^ 


Fig.  14. —External  Surface  of  the  Left  Cerebral  Hemisphere. 
{Dramen  from  a  brain  treated  icith  nitric  acid  ajid  dried) 


central  fissure 
pre-central  fissure 
parieto-occipital  fissure 
intraparietal  fissure 
Sylvian  fissure 
superficial  temporal  fissure 
second  temporal  fissure 
inferior  occipital  fissure 
anterior  occipital  fissure 
pre-central  gyrus 


B  post-central  g-yrus 

Ci  superior  frontal  pyrus 

(2  middle  frontal  pyrus 

C^  inferior  frontal  gyrus 

D  parietal  lobe 

E  marginal  gyrus 

F  angular  gyrus 

(t  occipital  lobe 

Ifx  first  temporal  gjTUS 

H^  second  temporal  gyrus 


The  most  important  anatomical  features  which  are  necessary 
for  clinical  work  are  here  briefly  presented. 

The  motor  tracts  proceed  from  the  psychomotor  centres  of  the 
cerebral  cortex  (Fig.  14). 


m 


DISEASES   OF   THE   NERVOUS   SYSTEM 


39 


Fig.  15. —  Outline  of  a  Transverse  Dorso-ventral  Section  of  the  Eight  Half 
OF  THE  Brain.     (Natural  size.)     (Sherrington.) 

OT,  optic  thalamus ;  Nc,  nucleus  caudatus  ;  the  head  only  appears  in  this  section  ; 
Pt,  putamen  ;  Gj)" ,  Gp\  the  two  parts  of  the  globus  pallidus  of  the  nucleus  lenticularis  ; 
(7,  the  claustrum  ;  CE,  the  external  capsule  ;  In,  the  island  of  Eeil ;  ca,  the  anterior 
«ommissure  shaded  to  render  it  distinct,  and  the  fibres  from  the  temporo-sphenoidal 
lobe  which  pass  into  it  being  indicated  by  broken  hues  ;  Op,  the  optic  tract ;  Zt'rf,  the 
end  of  the  descending  horn  of  the  lateral  ventricle;  F,  the  fornix  ;  F\  the  end  of  the 
anterior  pillar  of  the  fornix  in  the  base  of  the  thalamus  ;  cc,  corpus  callosum  ;  OP,  an- 
terior part  of  the  occipital  lobe. 

fc  is  the  central  fissure  or  fissure  of  Rolando.  The  course  of  the  fibres  of  the  pyram- 
idal tract  connected  respectively  with  the  trunk,  leg,  and  arm,  and  hence  with  spinal 
nerves,  and  of  those  connected  with  the  face  and  hence  with  cranial  nerves,  is  shown 
by  broken  lines.     These  are  all  seen  converging  into  the  internal  capsule,  CI. 


40  DISEASES   OF   THE   NERVOUS   SYSTEM  chap. 

The  centre  for  the  voluntary  movements  of  the  arm  lies  in  the 
middle  third  of  the  pre-central  convolution;  the  centre  for  the  face 
and  tongue  in  the  lower  third  of  the  same  convolution  ;  that  for 
the  motion  of  the  legs,  in  the  upper  third  of  both  the  pre-central 
and  post-central  gyri  and  in  the  para-central  lobule,  which  unites 
these  two  convolutions  on  the  mesal  face  of  the  hemisphere.  The 
motor  centres  of  speech  lie  in  the  posterior  part  of  the  left  inferior 
(third)  frontal  gyrus  and  in  the  insula  (island  o'f  Reil)  (between 
the  inferior  frontal  and  the  superior  temporal  gyri).  The  sensory 
speech  centre  lies  in  the  temporal  lobe  (first  left  temporal  gyi'us). 
The  cortical  visual  centre  is  situated  in  the  occipital  lobe  (for 
hemianopsia  see  p.  38,  cerebral  nerves),  the  cortical  auditory 
centre  in  the  temporal  lobe. 

The  motor  fibres  proceed  from  the  cortical  centres  through  the 
corona  radiata  to  the  internal  capsule  (Fig.  1.5). 

Here  will  be  found  the  pyramidal  (motor)  tract  in  the  middle 
third  of  the  posterior  half  of  the  internal  capsule,  and  between  the 
thalamus  and  lenticular  nucleus,  closely  bordering  on  the  fibres 
which  control  voluntary  facial  moA'ements.  This  location  is  the 
seat  of  predilection  for  cerebral  haemorrhages. 

Proceeding  through  the  internal  capsule,  the  motor  fibres  con- 
tinue to  the  pes  (ventral  portion  of  crus  cerebri)  ;  the  sensory  fibres 
proceed  through  the  tegmentum  (dorsal  portion  of  crus  cerebri) 
into  the  pons.  From  the  pons  they  go  into  the  medulla  (oblongata), 
where  they  constitute  the  pyramids,  and  there  decussate  for  the 
most  part.  In  the  spinal  cord  (Fig.  16)  the  decussated  motor  fibres 
proceed  downwards  in  the  crossed  pyramidal  tract,  the  very  few 
fibres  Avhich  did  not  decussate  proceeding  downwards  as  the  un- 
crossed (anterior)  pyramidal  tract. 

The  motor  fibres  proceed  from  the  pyramidal  tracts  to  the  an- 
terior cornua  of  the  central  gi'ay  matter  of  the  spinal  cord,  and  from 
there  leave  the  cord  by  way  of  the  anterior  spinal  roots  and  the 
peripheral  nerves  to  reach  the  muscles. 

The  trophic  centres  for  the  pyramidal  tract  lie  in  the  cerebrum, 
and  when  any  part  of  the  motor  tract  is  injured  there  ensues,  in 
addition  to  the  consecutive  paralysis,  a  descending  degeneration  of 
the  pyramidal  tract ;  tlie  trophic  centres  for  the  peripheral  ynotor 
nerves  lie  in  the  ganglion  cells  of  the  anterior  cornua.  A  lesion 
of  this  organ  or  one  peripheral  to  it  induces  degeneration  of  the 
nerves  and  paralysis  and  atrophy  of  the  muscles  supplied  by  the 
structures  concerned. 

The  sensory  tracts  run  upwards  in  the  posterior  columns  and 


Ill 


DISEASES   OF  THE   NERVOUS   SYSTEM 


41 


posterior  cornua  of  the  cord ;    they  decussate  immediately  after 
their  entry  and  also  in  the  lemniscus. 

COM.  flj^P/^^       CO. 


-Ksb 


-Fsh 


sip     )fgn 


Fig.  16. 


•Diagrammatic  Cross-section  of  the  Spinal  Cord  showing  the  Tracts 
OF  THE  White  Matter. 


c.a.    {co7'nu  anteriuH)  &TitQv'v)v  \iOYr].  f-Qi^- 

cl.    (eornu  laterale)  lateral  horn 
c.p.    {cormv  posterius) 'po?>tQv\QT  horn  f.cn. 

c.c.     central  canal  in  the  gray  commis- 
sure Ksb 
COM.     anterior  white  commissure 
r.a.     (radix  anterior)  anterior  root  Psb 
r.p.    (radix  posterior)  posterior  root 
f.l.a.     (ßssura    longitudinalis     ante-            Pvh 

rior)  anterior  fissure 
s.l.p.    (septianlonr/itudinalepjosterius)        v.  W.z. 
posterior  septum 

Paralysis 


(funiculus  gracilis)  Goll's  col- 
umn 

(funicuhis  cuneatus)  Burdach's 
column 

(Kleinhirnseitenbahn)  direct 
cerebellar  tract 

(Pyramid  alseitenbahn)  crossed 
pyramidal  tract 

(Pyramidalvorderbahn)  direct 
pyramidal  tract 

(Vordere  Wurzelzone)  anterior 
radicular  zone 


(The  absolute  inability  to  move  a  limb  is  called  j9a?'a??/s«'s; 
to  motor  weakness  of  a  limb  is  given  the  name  paresis.) 

When  the  presence  of  a  paralysis  or  paresis  is  determined, 
the  following  features  should  be  elicited  :  — 

1.  Is  the  paralysis  limited  to  one  side  of  the  body 
(hemiplegia,  for  example,   paralysis  of   the  right  arm  and 


42  DISEASES   OF  THE   NERVOUS  SYSTEM  chap. 

right  leg) ;  does  it  involve  both  sides  {loaraplegia,  e.g.,  both 
arms  or  both  legs) ;  or  is  it  limited  to  one  extremity  or  to  a 
group  of  muscles  {monoplegia,  e.g.,  one  arm,  or  the  servati 
group)  ?  All  hemiplegias  are  produced  by  lesions  of  the 
cerebrum,  paraplegias  by  lesions  of  the  spinal  cord,  although 
multiple  neuritis  occasionally  is  the  cause  of  the  latter. 
Monoplegias  depend  upon  lesions  either  of  the  cerebrum 
or  of  the  peripheral  nerves. 

2.  Is  the  affected  member  y?acc?VZ  or  spastic  ? 

Flaccid  paralyzed  limbs  are  easy  to  move  by  passive  motion, 
but  a  spastic  condition  of  the  limb  presupposes  an  extensive  re- 
sistance to  any  attempts  of  motion,  or  a  convulsive  contraction 
ensues  on  such  attempt.  The  reflexes  in  the  latter  condition  of 
spastic  paralysis  are  increased  in  the  affected  limb. 

Spastic  conditions  ensue  when  contracture  develops  in  the 
paralyzed  muscles  or  in  their  antagonists,  and  further  in  those 
conditions  of  increased  reflexes  like  those  accompanying  degenera- 
tion of  the  pyramidal  tract. 

3.  Does  atrophy  exist?  Atrophic  palsies  depend  upon 
lesions  of  the  peripheral  nerves  or  of  the  anterior  cornua  of 
the  spinal  cord,  or  of  the  cranial  nerve  nuclei  or  of  the  pons. 

The  organic  paralyses  are  in  direct  contrast  to  the  func- 
tional, which  do  not  depend  upon  anatomical  causes  but 
upon  an  affection  of  volition  (hysterical  paralysis,  paralysis 
of  fright).  The  functional  palsies  are  recognized  by  the 
following  criteria :  there  is  an  absence  of  trophic  and  elec- 
trical disturbances ;  there  are  present  and  coincident  with 
the  palsy  certain  definite  signs  of  hysteria,  such  as  hemian- 
aesthesia,  convulsions,  contractures,  etc. ;  above  all  they  may 
be  recognized  by  the  general  psychical  character  of  the 
patient. 

Hemiplegia 

It  is  important  in  this  condition  to  determine  the  etiology 
and  to  locate  the  part  of  the  cerebrum  which  is  involved 
in  the  process  producing  this  symptom  (localization). 


Ill  DISEASES   OF  THE   NERVOUS   SYSTEM  43 

Etiology 

1.  Embolism.  The  hemiplegia  is  suddenly  produced,  in- 
volves chiefly  the  Sylvian  artery,  and  is  thereby  associated 
with  motor  aj)hasia.  It  is  necessary  to  determine  the  origin 
of  the  source  of  the  embolism,  e.g.,  affections  of  the  left  side 
of  the  heart. 

2.  Apoplexy.  It  appears  suddenly,  and  is  proven  by  an 
existing  arterio-sclerosis  or  of  contracted  kidney.  It  in- 
volves chiefly  the  large  central  ganglia  (corpus  striatum, 
internal  capsule)  (Fig.  15),  and  occurs  frequently  without 
aphasia.  It  is  usually  accompanied  by  a  long-continued 
comatose  condition. 

3.  Syphilis.  It  may  be  the  result  of  a  focal  softening 
induced  by  the  closure  of  an  artery  whose  walls  have  been 
the  seat  of  a  syphilitic  endarteritis.  It  develops  slowly, 
and  is  often  preceded  by  prodromal  headaches  and  vertigo ; 
often  there  develop  other  focal  lesions,  manifesting  them- 
selves at  times  in  ocular  palsies,  paralysis  of  muscles  on 
the  other  side  of  the  body,  disturbance  of  speech  such  as 
anarthria.  The  proof  of  an  existing  or  preexisting  syphilis 
will  assist  in  determining  the  etiological  factor  of  the 
hemiplegia.  Very  often  antisyphilitic  treatment  produces 
a  favorable  result. 

4.  Simple  focal  softening  due  to  arterio-sclerosis.  The 
diagnostic  factors  in  this  case  are  old  age,  existing  arterio- 
sclerosis, absence  of  syphilis,  no  improvement  with  anti- 
syphilitic  treatment. 

5.  Toxic  causes.  It  occurs  with  uraemia,  in  the  last 
stages  of  carcinoma  and  phthisis,  and  is  then  evanescent 
and  atypical  in  character. 

It  is  wise  to  regard  tentatively  that  hemiplegias  occurring 
in  the  young  are  of  syphilitic  basis,  and  to  always  subject 
all  those  patients  in  whom  there  is  a  doubt  as  to  the  etio- 
logical factor  to  antisyphilitic  treatment. 


44  DISEASES   OF   THE   NERVOUS   SYSTEM  chap. 

Localization  of  the  lesion  giving  rise  to  hemiplegia  may 
often  be  determined  b}^  the  simultaneous  involvement  of 
the  cerebral  nerves  and  speech. 

The  following  focal  lesions  should  be  chiefly  borne  in 
mind:  1.  Hemiplegia  with  motor  aphasia  indicates  a  lesion 
of  the  third  left  frontal  convolution.  2.  Hemiplegia  with 
lower  facial  palsy,  a  lesion  in  the  posterior  half  of  the 
internal  capsule.  3.  Hemiplegia  with  hemiansesthesia,  a 
lesion  in  the  posterior  division  of  the  same  half  of  the  in- 
ternal capsule,  4.  Hemiplegia  with  alternating  (crossed) 
ocular  palsy,  a  lesion  in  crus  cerebri.  5.  Hemiplegia  with 
alternating  (crossed)  facial  paralysis  (Gubler),  a  lesion  of 
the  pons.  6.  Hemiplegia  with  anarthria  and  deglutitory 
palsy,  a  lesion  of  the  medulla  oblongata. 

Paraplegia 

It  is  necessary  to  decide  whether  the  paraplegia  is  the 
result  of  a  lesion  of  the  spinal  cord  or  of  a 2jeri2Jheral  neuritis. 
All  spastic  paraplegias  may  be  assigned  to  spinal  cord 
lesions.  The  following  features  must  be  determined  in  a 
flaccid  ^  paraplegia :  1.  Whether  the  sphincters  (bladder, 
rectum)  are  involved,  a  condition  which  arises  only  in  spinal 
cord  disease.  2.  The  reflexes;  they  are  absent  in  neuritis, 
and  are  exaggerated  in  spinal  cord  disease.  3.  The  eti- 
ology" ;  paralysis  due  to  alcohol  is  of  peripheral  origin. 

In  a  few  individual  cases  it  may  be  extraordinarily  difficult  to 
differentiate  between  poliomyelitis  (a  disease  of  the  gray  substance 
of  tlie  cord)  and  a  peripheral  neuritis,  because  in  exceptional  cases 
the  involvement  of  the  sphincters  occurs  in  neuritis;  just  as  the 
reflexes  may  in  the  same  manner  be  exaggerated  in  the  hyper- 
aesthetic  stage  of  a  neuritis,  so  may  the  reflexes  be  absent  in  a  deep 
myelitis  which  destroys  the  reflex  arc. 

1  May  we  use  this  adjective  to  denote  what  is  expressed  in  the  German 
"schlaffen  Paraplegien  "  ?  Tlie  author  means  the  paraplegia  associated 
with  tiaccid,  liini>,  or  relaxed  muscles,  as  the  antithesis  to  the  spastic 
parai>legia.  —  The  Translators. 


Ill  DISEASES   OF   THE   NERVOUS   SYSTEM  45 

Should  the  diagnosis  of  a  cord  lesion  be  made,  it  is 
necessary  to  establish  the  following  data:  — 

1.  The  seat  and  extent  of  the  disease ;  paralysis  of  both 
legs  indicates  a  lesion  in  the  lumbar  and  lower  dorsal  seg- 
ments of  the  cord ;  paralysis  of  both  legs  and  arms,  a  lesion 
of  the  upper  dorsal  and  cervical  segments. 

2.  The  nature  of  the  pathological  process,  whether  a 
myelitis,  a  tumor  (aneurysm  very  seldom  occurs),  carcinoma, 
tubercular  caries,  or  syphilis.  A  tumor,  or  caries,  must  be 
palpable  (the  vertebra  must  be  carefully  examined),  car- 
cinoma and  tuberculosis  in  other  organs  must  be  demon- 
strated in  order  to  establish  a  positive  result.  The  clinician's 
thoughts  should  turn  to  aneurysm  if  there  be  a  concomi- 
tant arterio-sclerosis  or  an  idiopathic  cardiac  dilatation ;  to 
syphilis  if  the  cranial  nerves  be  also  involved,  or  if  a  specific 
infection  is  conceded. 

In  all  doubtful  cases  antisyphilitic  treatment  should  be 
given. 

Paralyses  of  the  Cerebral  and  Spinal  Ner^t:s 

Paralysis  of  the  cranial  nerves.  This  is  recognized  by  the 
defective  function  of  the  muscles  supplied  by  them,  and  can 
be  determined  by  the  anatomical  relations  (Fig.  17). 

The  most  important  signs  are  here  mentioned  :  — 

Olfactory  lesion  is  to  be  determined  by  disturbance  of  the  sense 
of  smell,  which  should  be  tested  by  the  use  of  odorous  but  not 
irritating  substances  (musk,  asafoetida).  Still  one  must  bear  in 
mind  the  possibility  of  disease  of  the  nasal  mucous  membrane  and 
of  nasal  occlusion. 

Optic  nerve  lesioti  will  be  indicated  by  diminution  of  vision, 
limitation  of  the  visual  field,  color-blindness.  (In  every  case  an 
ophthalmoscopic  examination  should  be  made.) 

Hemianopsia  or  hemiopia  (the  loss  of  sensation  in  one  half  of 
the  retina  of  each  side)  depends  upon  lesion  of  the  occipital  lobe 
or  of  the  optic  tract  as  far  as  the  chiasm.  The  focal  lesion  is 
cephalad  to  the  corpora  quadrigemina  in  homonymous  hemianopsia 
when  the  pupillary  light  reaction  is  normal;  on  the  other  hand. 


46 


DISEASES   OF  THE   NERVOUS   SYSTEM 


CHAP. 


should  the  pupillary  reflex  be  absent  for  those  visual  rays  which 
fall  upon  the  paralj^zed  halves  of  the  retina,  the  cause  of  the  hemi- 
anopsia must  be  sought  ventral  to  the  corpora  quadrigemina  or  in 
the  optic  tract.  The  latter  condition  is  called  hemianopic  iridoplegla 
or  hemiopic  pupillary  reaction.     Amblyopia  or  amaurosis  of  one  eye 


Lobus  front. 


Fossa  Sylvii 


A.  corporis 
callosi 

A.  fossae 

Sylvii        -H:^-  -«?'' 


^(, 


<V"       '*^.     i    ^      I  ll  '/f-r--v-   --l..i.....L..     N.I, 
oi-"-— r^,.-?:^         rllflfo     I    I    , W^        \      f\olfactc 


olfactorius 


Corpus  calloa. 


Lobus  temper. 


N.V.trigeminus 

N.VI.abducens 
N. VII. facialis 
N.VIII.acusticus 
K.IX.X.XI. 


Fig.  17. — The  Base  of  the  Bbain  and  the  Ceakial  Nerves.   (After  Henke.) 

indicates  lesion  of  the  optic  nerve  anterior  to  the  chiasm ;  it  may 
also  be  induced  by  toxic  influences  (tobacco  amblyopia,  ursemic 
amaurosis). 

Motor  oculi  paralysis  is  shown  by  a  divergent  strabismus,  dilata- 
tion of  the  pupil  (mydriasis),  double  vision  (diplopia),  closure  of 
the  upper  eyelid  (ptosis). 

Recurrent  ocular  motor  paralysis  accompanies  conditions  of  mi- 
graine, which  may  last  for  weeks  or  months  (migi-aine  ophthalraique 


m  DISEASES  OF  THE   NERVOUS   SYSTEM  47 

of  Cliarcot),  but  in  such  cases  the  doubt  of  an  organic  cerebral 
lesion  (paretic  dementia)  should  always  be  entertained. 

Mydricms  may  also  be  produced  by  an  irritation  of  tlie  sympa- 
thetic, such  as  results  from  migraine,  trauma,  pressure,  diseases  of 
the  cervical  cord,  poisoning*  from  atropine,  cocaine,  etc.  It  may 
be  also  reflex,  as  in  great  fright,  severe  dyspnoea,  intense  pain. 

Myosis,  contraction  of  the  pupil,  depends  upon  an  irritation  of  the 
motor  oculi  or  lesion  of  the  cervical  sympathetic ;  it  is  unilateral 
in  migraine,  and  may  be  the  result  of  the  pressure  of  a  tumor  on 
the  cervical  sympathetic  ;  it  is  bilateral  in  affections  of  the  cervical 
cord  and  in  atropine  and  pilocarpine  poisoning,  etc.  Concerning 
reflex  iridoplegia,  see  p.  56. 

Trochlear  is  paralysis  is  shown  by  the  inability  to  move  the  eyes 
upwards  and  outwards. 

In  ahducens  paralysis  the  eye  can  not  be  moved  outwards. 

Certain  abnormal  positions  of  both  ocular  globes  point  towards 
central  focal  lesions  (associated  palsies,  nuclear  palsies);  for  in- 
stance, both  eyes  are  immovably  fixed  looking  to  the  right. 

When  the  muscles  of  mastication  will  not  perform  their  func- 
tion, it  indicates  a  pa-ralysis  of  the  motor  division  of  the  trigeminus. 

Facial  palsy  is  indicated  by  a  loss  of  function  of  the  muscles  of 
expression.  The  exact  seat  of  the  lesion  which  produces  the 
interruption  of  motor  conduction  may  be  determined  according 
as  the  sense  of  taste,  the  salivary  secretion,  hearing,  the  uvula  may 
be  involved  (Erb's  scheme). 

Disturbances  of  hearing  may  indicate  an  acusticus  affection.  An 
otoscopic  examination  should,  however,  decide. 

Glossopharyngeal  paralysis  is  indicated  by  a  disturbance  of  taste 
in  the  posterior  part  of  the  tongue. 

Hypoglossal  lesion  is  shown  by  the  deviation  of  the  tongue  to 
one  side  or  the  other. 

Spinal  accessory  lesion  produces  a  paralysis  of  the  sterno-cleido- 
mastoid  and  trapezius. 

Pneu7no gastric  lesion  presents  an  increase  in  pulse  beat  and  a 
slowing  of  respiration. 

Lesions  of  the  nerves  of  the  cord  are  recognized  by  the 
loss  of  function  of  the  muscles  which  they  supply. 

Only  the  symptom  groups  which  commonly  appear  are  here 
noticed :  — 

Erh's  paralysis  is  the  paralysis  of  the  deltoid,  biceps,  brachialis 


48  DISEASES   OF   THE   NERVOUS   SYSTEM  chap. 

anticus,  supinator  loiigus,  and  the  iufiaspinatus.  It  is  due  to  a 
lesion  of  the  brachial  plexus  (5th  to  8th  cervical  and  1st  to  2d 
dorsal  nerves). 

Median  nerve  lesion.  Tn  this  affection,  it  is  impossible  to  pro- 
nate  the  forearm  and  flex  the  hand;  likewise  the  flexors  of  the 
thumb,  and  their  antagonists,  and  the  flexors  of  both  the  last 
phalanges  are  involved.  The  proximal  phalanges  can  be  flexed, 
and  the  third,  fourth,  and  small  fingers  are  capable  of  motion. 

Ulnar  nerve  lesion.  Flexion  and  motion  of  the  hand  to  the 
ulnar  side  and  flexion  of  the  third  finger  are  disturbed.  The 
small  finger  is  motionless.  The  proximal  phalanges  can  not  be 
flexed.  Extension  of  the  terminal  phalanges  of  the  last  four 
fingers,  and  abduction  and  adduction  of  them  are  impossible. 
When  the  affection  is  of  long  standing,  the  characteristic  picture 
of  the  ''  claw  hand  "  is  presented ;  in  this  case  the  first  phalanges 
are  strongly  extended,  the  end  phalanges  completely  flexed,  and 
the  interossei  muscles  are  much  atrophied. 

Radial  nerve  lesion.  The  hand  hangs  in  the  condition  of  flex- 
ion, perfectly  limp,  and  can  not  be  extended.  The  fingers  are  flexed, 
the  first  phalanx  can  not  be  extended.  The  thumb  is  flexed  and 
adducted  and  can  neither  be  abducted  nor  extended.  The  ex- 
tended forearm  can  not  be  supinated ;  in  the  condition  of  flexion, 
however,  supination  may  occur  by  action  of  the  biceps. 

Phrenic  nerve  lesion  produces  paralysis  of  the  diaphragm,  with 
its  characteristic  modification  of  respiratory  movements;  that  is, 
forcible  superior  thoracic  respiration  without  the  inspiratory  pro- 
trusion of  the  epigastrium. 

Peroneal  nerve  lesion  produces  the  characteristic  limp  drooping 
of  the  foot,  especially  noticeable  on  walking.  Dorsal  flexion  of 
the  foot  and  toes,  abduction  of  the  foot,  and  elevation  of  its  outer 
border  are  impossible.  When  of  long  duration  there  results  a 
permanent  position  of  the  foot  which  necessitates  the  walking  on 
the  toe  tips  (pes  equinus). 

Tibial  nerve  lesion  produces  a  loss  of  plantar  flexion  of  the  foot 
(the  patients  can  not  stand  on  their  toe  tips)  as  well  as  adduction 
of  the  foot  and  plantar  flexion  of  the  toes. 

The  diagnosis  of  lesions  of  the  cranial  or  of  the  spinal 
nerves  requires,  irrespective  of  a  knowledge  of  the  ana- 
tomical relations,  an  investigation  of  the  following  data: 
1.  The  cause  must  be  determined,  whether  trauma,  pressure, 


Ill  DISEASES   OF   THE   NERVOUS   SYSTEM  49 

exposure,  or  an  infectious  inflammation  due  to  acute  or 
chronic  disease.  2.  The  intensity  of  the  disease.  This  is 
recognized  by  the  character  of  the  electrical  reactions  (see 
p.  64).  Three  forms  are  recognized :  a.  The  mild  form, 
characterized  by  a  normal  electrical  reaction  of  the  para- 
lyzed muscles,  h.  Erb's  middle  form  by  a  partial  reaction 
of  degeneration.  In  these  cases  the  irritability  of  the  nerve 
diminishes  without  being  extinguished,  while  the  galvanic 
irritability  of  the  muscles  on  direct  application  of  the  cur- 
rent to  them  is  increased ;  the  anode  closure  contraction  is 
greater  than  the  cathode  closure  contraction,  AnCc  >  CaCc ; 
all  contractions  are  slow.  c.  The  intense  form,  character- 
ized by  the  complete  reaction  of  degeneration,  which  mani- 
fests itself  in  a  complete  loss  of  faradic  and  galvanic 
irritability  of  the  nerves,  loss  of  faradic  irritability  of  the 
muscles,  in  a  quantitative  and  qualitative  change  in  the  gal- 
vanic irritability  of  the  muscles ;  the  contractions  resulting 
from  the  application  of  an  electrical  stimulus  are  slow  and 
wavelike.  The  anode  closure  contraction  is  equal  to  the 
cathode  closure  contraction,  AnCc  =  CaCc. 

Speech  disturbance.  — It  is  necessary  to  distinguish  between 
speech  disturbance  due  to  functional  inactivity  of  the  muscles 
(anartJiria)  and  defective  speech  production  where  the  mus- 
cular apparatus  is  wholly  intact  (cipliasia).  Anarthria  is  the 
result  of  a  lesion  of  the  medulla  oblongata  (bulbar  symptom). 

In  aphasia  one  must  determine  whether  the  patient  has  a 
true  conception  of  the  spoken  word  and  is  prevented  only  in 
transferring  the  proper  concept  into  speech  (^motor  aphasia 
or  ataxic  aphasia),  or  whether  the  conception  of  speech  is  so 
lost  that  he  does  not  understand  the  sense  of  the  word  pro- 
nounced to  him  and  is  unable  himself  to  produce  word  con- 
cepts {sensory  aphasia  or  amnesic  aphasia).  The  site  of  the 
lesion  producing  ataxic  aphasia  is  in  the  convolution  of 
Broca,  the  third  left  frontal  convolution;  that  of  sensory 
aphasia  is  in  the  first  left  temporal  convolution. 

£ 


50  DISEASES   OF  THE   NETlVOUS   SYSTEM  chap. 

Motor  ai^hasia  very  frequently  is  associated  with  the  inability 
to  write,  though  the  motor  apparatus  of  the  upper  extremity  be 
intact  {arjraphia),  while  sensory  aphasia  may  be  associated  with 
an  inability  to  read,  though  perfect  vision  may  be  present  {alexia). 

Ataxia  is  the  inability  to  execute  complex  movements  in  a 
skilful  manner  when  there  is  no  disturbance  of  the  motor 
apparatus ;  in  other  ^vords,  the  inability  to  properly  coor- 
dinate muscular  action.  It  is  most  probably  induced  in  this 
wise :  after  the  destruction  of  the  centripetal  conduction 
paths,  the  movements  are  no  longer  controlled  by  the  fine 
sensory  impressions.  Ataxia  is  the  chief  symptom  of  tabes; 
it  occurs  also  in  peripheral  neuritis,  is  sometimes  consecutive 
to  alcoholism  and  diphtheria;  in  addition,  it  occurs  in 
lesions  of  the  cerebellum. 

Ataxia  of  the  hands  is  determined  by  having  the  patient,  with 
his  eyes  closed,  button  his  coat,  by  having  him  write,  etc.  Ataxia 
of  the  legs  may  be  demonstrated  by  having  the  patient  touch  the 
knee  of  the  left  leg  with  the  foot  of  the  right,  or  to  describe  an  arc 
of  a  circle,  etc.  Ataxia  is  more  exaggerated  when  the  patient  is  in 
the  dark. 

Roniherg  symptom  is  the  swaying  of  the  body  while  stand- 
ing with  closed  eyes.  It  occurs  chiefly  in  tabes,  but  may 
also  be  present  in  neurasthenia. 

Gait.  Slight  disturbances  of  motion  or  of  coordination 
of  the  legs  may  be  distinctly  recognized  in  the  patient's 
walk ;  thus  the  silastic,  the  paretic,  and  the  ataxic  gait  are 
spoken  of. 

Motor  Irritative  Phenomena 

Spasm.  We  designate  clonic,  that  is,  interrupted,  short 
contractions,  when  involving  the  entire  body,  as  convulsions ; 
long-continued  contractions  are  known  as  tonic  spasms; 
when  spread  over  the  greatest  part  of  the  skeletal  muscular 
system,  it  is  called  tetanus. 

Clonic  and  tonic  spasms  appear  in :  — 

1.   Epilepsy.      In  this  affection  they  are  first  tonic,  subse- 


HI  DISEASES   OF  TPIE   NERVOUS   SYSTEM  51 

quently  they  become  clonic,  and  are  accompanied  by  total 
loss  of  consciousness,  which  persists  throughout  the  attack, 
with  dilated  pupils,  which  will  not  react.  The  face  is  at  first 
pale,  then  becomes  cyanosed,  and  the  tongue  is  often  bitten. 

2.  Eclampsia  of  pregnant  and  parturient  women,  com- 
monly accompanied  by  dropsy  and  albuminuria. 

3.  Ur(jemia  appearing  in  the  course  of  acute  and  chronic 
nephritis ;  in  a  few  cases  the  nephritis  may  have  been  un- 
perceived,  and  the  first  indication  of  the  uraemic  character 
of  the  spasms  may  only  have  been  determined  by  the  dis- 
covery of  albumin  in  the  urine. 

4.  As  the  result  of  a  direct  irritation  of  the  cerebral 
motor  centres,  occasioned  by  tumor,  abscess,  Cysticercus,  etc. 

5.  In  children  as  a  consequence  of  the  increased  reflex 
irritability  accompanying  febrile  diseases,  dentition,  indiges- 
tion, worms. 

Pure  tonic  spasms  are  a  feature  of :  — 

1.  Tetany.  They  are  chiefly  confined  to  the  flexor  mus- 
cles of  both  arms  and  both  legs.  The  duration  of  the  attacks 
may  vary  from  minutes  to  hours,  seldom  days.  As  a  rule, 
there  are  several  attacks  daily.  The  attack  may  be  pro- 
duced by  pressure  upon  the  larger  arteries  and  nerve-tranks 
of  the  arm  {Trousseau  phenomenon).  The  temperature  is 
normal.  During  the  period  of  repose  after  the  subsidence 
of  an  attack,  the  mechanical  and  electrical  irritability  of  the 
peripheral  nerves  is  increased.     The  prognosis  is  favorable. 

2.  Tetanus.  The  tonic  spasms  in  this  disease  are  confined 
chiefly  to  the  muscles  of  the  face,  producing  trismus  and  risus 
sardonicus ;  to  the  muscles  of  the  back,  resulting  in  opistho- 
tonus, and  to  the  abdominal  muscles  ;  those  of  the  arms  and 
legs  are  not  as  often  affected.  The  continuous  spasms  are 
interrupted  by  attacks  of  jerking.  The  temperature  of  the 
body  is  increased,  and  hyperpyrexia  is  marked  before  death. 

Tn  cases  of  tetanus  the  diagnosis  should  also  embrace  a  determi- 
nation of  the  cause  and  the  search  for  the  existing  wound  through 


52  DISEASES   OF   THE   NERVOUS    SYSTEM  chap. 

which  the  tetanus-bacillus  entered  the  system.  The  wound  will 
often  be  found  to  be  very  slight,  or  even  already  healed.  The 
prognosis  may  be  more  favorably  affected  ,at  times  when  the  for- 
eign body  (splinter,  etc.)  which  caused  the  wound  has  been  re- 
moved. It  is  also  important  to  determine  the  period  of  incubation; 
the  longer  the  duration  of  this,  the  better  the  prognosis. 

Localized  spasm  in  the  course  of  distribution  of  certain 
nerves  results  partly  as  a  reflex  phenomenon,  and  partly  as 
an  individual  disease  in  neuropathic  subjects. 

Localized  tonic  spasm  occurs  along  the  course  of  the  trigeminus, 
in  the  muscles  of  mastication  (trismus),  in  tetanus,  meningitis, 
epilepsy,  hysteria.  In  such  cases  artificial  feeding  may  have  to 
be  used. 

Painful  spasm  of  the  legs  (cramp)  is  often  noticed  after  strong 
muscular  effort,  in  the  hysterical  and  the  alcoholist,  and  in  isolated 
cases  of  gout  and  diabetes. 

Rhythmical  contractions  which  repeat  themselves  and  which  are 
partly  continuous  and  partly  occur  at  intervals  are  called  tic 
convulsif.  We  recognize  tic  convulsif  in  the  distribution  of  the 
facial  (spasm  of  the  muscles  of  mimicry),  of  the  spinal  accessory 
(tic  of  the  sterno-cleido-mastoid),  seldom,  though,  in  the  distribu- 
tion of  the  spinal  nerves  (tic  of  the  rectus  abdominis,  of  the  psoas). 

Intention  spasm  or  tonic  spasm,  occurring  at  the  beginning 
of  voluntary  movements  of  the  muscles,  is  the  pathogno- 
monic symptom  of  Thomseu's  disease  (myotonia  congenita). 
This  disease  is  one  of  lifelong  duration. 

Every  voluntary  muscle  which  had  been  previously  at  rest  be- 
comes, when  put  into  action,  the  seat  of  a  mild  tetanic  contraction; 
the  patient  can  not  immediately  relax  the  muscle  at  command,  he 
is,  therefore,  unable  to  carry  out  coordinated  movements;  after 
long  tedious  motion  the  contraction  becomes  less  intense.  The 
electrical  reaction  is  peculiarly  altered,  giving  rise  to  the  myotonic 
reaction  of  Erb. 

Tremor  in  muscles  at  rest  is  the  sign  in  nervous  people  of 
intense  psychical  excitement.  Persistent  tremor  without  any 
pathological  signiticance  occurs  often  in  old  people  (tremor 
senilis),  but  it  is  characteristic  of  chronic  alcoholism  and  of 


Ill  DISEASES   OF   THE    NERVOUS   SYSTEM  53 

Basedow's  disease.      Extensive  tremulous  movement  is  sig- 
nilicant  of  paralysis  agitans. 

The  tremor  is  slow  (5  to  6  oscillations  in  a  second)  in  the  senile, 
in  sclerosis  and  in  paralysis  agitans;  it  is  quicker  (10  to  12  oscil- 
lations) in  alcoholics  and  in  Basedoiv's  disease. 

Tremor  in  voluntary  muscles  which  are  put  into  exercise 
(intention  tremor)  is  pathognomonic  for  multiple  sclerosis; 
it  disappears  during  sleep,  however. - 

Tremor  of  the  eyes  (njjstagmus)  occurs  in  multiple  scle- 
rosis, in  workmen  who  having  been  confined  in  the  dark  are 
suddenly  exposed  to  light  (nystagmus  of  miners),  in  hysteria, 
and  in  certain  nervous  affections  of  the  eyes. 

Choreic  movements,  involuntary  uncoordinated  movements, 
which  embarrass  voluntary  movements  and  interrupt  them, 
and  which  only  cease  during  sleep,  are  xjathognomonic  of 
chorea  (St.  Vitus's  dance),  which  is  a  functional  neurosis. 
They  occur  very  seldom  in  cerebral  lesions. 

Choreic  movements  also  appear  as  an  indication  of  an  intense 
cerebral  intoxication  in  infectious  diseases,  as  in  tj^phoid  and 
miliary  tuberculosis. 

The  following  are  not  of  essential  significance  :  — 

Athetoid  movements.  They  are  involuntary  peculiar  abductions 
and  flexions  of  the  fingers  indicative  of  a  special  affection  (athetosis) 
or  are  a  symptom  of  certain  central  nervous  affections  (especially  of 
cerebral  palsies  of  children) . 

Imperative  movements  are  noteworthy  in  lesions  of  the  cerebellum; 
they  occur  as  coordinated  spasmodic  movements  (laughing  spasms, 
screaming  spasms,  jumping  spasms)  in  hysteria  and  epilepsy. 

Cataleptic  rigidity  of  the  muscles  is  noticeable  in  hysteria,  in  the 
hypnotic  state,  also  in  meningitis,  in  certain  psychoses  (melancholia 
attonita) .  The  limbs  remain  fixed  immovably  in  any  position  in 
which  they  may  be  placed. 

The  Eeplexes 

It  is  necessary  to  distinguish  between  skin  and  mucous 
membrane  reflex,  tendon  reflex,  and  reflex  function,  whose 
relations  to  each  other  may  often  be  entirely  different. 


54  DISEASES   OF   THE   NERVOUS   SYSTEM  chap. 

By  skin  reflex  is  meant  the  muscular  contractions  induced 
in  a  reflex  manner  by  irritation  of  the  sensory  nerves  of 
the  skin. 

This  reflex  may  be  elicited  by  tickling,  pricking,  stroking, 
by  cold  (touching  with  ice). 

The  usual  examination  comprises  a  test  of  :  — 

1.  The  plantar  reflex,  produced  by  irritating  the  sole  of  the  foot, 
which  is  followed  by  a  dorsal  flexion  of  the  foot  and  even  of  a 
flexion  of  the  lower  extremity  on  to  the  abdomen. 

2.  The  cremaster  reflex.  Stroking  the  inner  aspect  of  the  thigh 
produces  reflex  movement  of  the  testicle. 

3.  The  abdominal  reflex,  produced  by  irritating  the  skin  of  the 
abdomen,  which  induces  a  contraction  of  the  abdominal  muscles  of 
the  same  side. 

4.  Gluteal,  scapular,  mamillary  reflexes  are  of  slighter  impor- 
tance, and  are  often  absent  under  normal  conditions. 

Diminution  or  loss  of  the  skin  reflex  always  results  when 
the  reflex  path  (centripetal  nerve,  anterior  cornu  of  the 
cord,  and  motor  nerve)  is  interrupted ;  therefore  it  is  to  be 
found  in  disease  of  the  peripheral  nerves  and  of  the  spinal 
cord. 

Increase  of  skin  reflex  occurs  in :  1.  Cases  of  increased 
irritability  of  the  parts  concerned  in  the  reflex  arc :  hyper- 
aesthesia  of  the  skin,  strychnia  intoxication,  certain  neuroses. 
2.  Cases  of  restoration  of  certain  interrupted  processes,  as 
in  diseases  of  the  brain  and  spinal  cord. 

The  mucous  mendu'ane  reflexes  are:  1.  Conjunctival  and  corneal 
reflexes,  wliich  manifest  themselves  in  closure  of  the  eyes  when 
the  conjunctiva  and  cornea  are  respectively  touched.  2.  Retching, 
l)y  irritation  of  tlie  pharynx.  3.  S7ieezin(j,  when  the  nasal  mucous 
membrane  is  irritated.  4.  Coughing,  on  irritation  of  that  of  the 
larynx  and  respiratory  passages. 

Tendon  reflex  is  the  term  applied  to  the  contraction  of  a 
muscle  which  is  induced  ])y  irritation  of  its  tendon,  perios- 
teum, or  fascia. 


Ill  DISEASES   OF  THE   NERVOUS   SYSTEM  55 

1.  Patellar  reflex  (knee  jerk,  knee  phenomenon).  If  the  patellar 
tendon  be  struck  by  a  percussion  hammer  ^  while  the  leg  is  flexed 
and  hangs  perfectly  flaccid  or  limp,  the  leg  is  thrown  into  a  for- 
wards and  backwards  movement  by  the  resnlting  contraction  of 
the  quadriceps  extensor  muscle.  It  is  necessary  in  eliciting  this 
phenomenon  that  the  attention  of  the  patient  be  withdrawn  from 
his  knee.  For  this  purpose  it  is  well  to  make  use  of  Jendrassilc's 
trick :  to  have  the  patient  clasp  his  hands  across  his  chest  and  to 
pull  "at  them  with  all  his  strength;  at  the  moment  in  which  he  is 
exerting  the  pull,  the  tendon  should  be  struck  unexpectedly. 

2.  Achilles  tendon  reflex.  The  Achilles  tendon  should  be  sud- 
denly struck  while  the  foot  of  the  patient  is  slightly  flexed;  the 
gastrocnemius  will  thereupon  distinctly  contract.  This  reflex  may 
be  absent  even  in  the  normal  person. 

3.  Foot  clonus  (foot  phenomenon).  The  foot  should  be  suddenly 
and  forcibly  flexed  dorsally  while  the  knee  is  slightly  flexed  ; 
whereupon  there  follows  an  energetic  tremor  of  the  foot.  It  is 
very  seldom  found  in  health. 

4.  Tendon  reflexes  of  the  upper  extremity  appear  very  seldom 
in  normal  conditions. 

The  loss  of  tendon  reflexes  occurs  whenever  there  is  an 
interruption  or  break  in  the  reflex  arc.  The  reflex  path  is 
by  v^ay  of  the  sensory  nerves,  the  posterior  columns  of  the 
cord,  the  anterior  cornua,  and  the  motor  nerves.  Hence  the 
tendon  reflexes  are  absent  in  all  peripheral  lesions,  such  as 
multiple  neuritis,  diphtheritic  and  alcoholic  neuritis,  and 
traumatic  lesion,  in  the  degenerations  of  the  posterior  col- 
umns, as  in  tabes,  and  in  the  diseases  of  the  gray  substance 
of  the  lumbar  cord,  as  in  poliomyelitis. 

Recently  the  loss  of  tendon  reflex  has  been  demonstrated  in 
cachectic  conditions  as  they  occur  in  pernicious  anaemia,  and  in 
the  grave  form  of  diabetes. 

Exaggeration  of  reflexes  occurs  whenever  the  reflex  in- 
hibitory centres  are  diseased.  These  centres  are  probably 
situated  in  the  brain,  and  send  out  their  impulses  along 
paths  which  proceed  through  the  pyramidal  tracts  of  the 

1  The  finger  i\\)s  will  answer  the  same  purpose.  — The  Translators. 


56  DISEASES   OF   THE   NERVOUS   SYSTEM  chap. 

cord.  Therefore  exaggeration  of  the  reflexes  will  be  found 
in  cerebral  paralysis,  as  well  as  in  chronic  myelitis ;  that 
is,  in  that  form  which  gives  rise  to  spastic  paralysis. 

Reßex  functions :  1.  Pupillary  reaction  to  light  and  to 
accommodation. 

The  pupillary  sphincter  muscle  is  supplied  by  the  motor  oculi 
nerve  and  the  pupillary  dilator  by  the  sympathetic.  Irritation 
of  the  motor  oculi  results  in  contraction  of  the  pupil;  irritation  of 
the  sympathetic  produces  pupillary  dilatation.  To  these  conditions 
the  respective  names  of  myosis  and  mydriasis  are  given.  Paralysis 
of  the  motor  oculi  produces  dilatation,  that  of  the  sj'mpathetic, 
contraction  of  the  pupil.  The  centre  is  said  to  be  placed  in  the 
inferior  cervical  segment  of  the  cord  {centrum  cilio-spinale). 
(Compare  p.  47.) 

The  pupillary  reaction  may  be  absent  in  various  cerebral 
affections.  Reflex  irkloplegia  is  of  very  great  importance  as 
a  diagnostic  sign  of  tabes  dorsalis.  It  shows  itself  as  fol- 
lows :  the  pupil  contracts  on  accommodation,  but  not  to  light. 
At  the  same  time  it  very  frequently  occurs  in  tabes  that  the 
pupils  are  extremely  small  {myosis  spinalis)  and  unequal  in 
size.  E-eflex  iridoplegia  further  is  an  early  symptom  of 
paretic  dementia. 

2.  Disturbances  of  defecation  and  of  micturition,  as  well 
as  of  the  sexual  reflex  (vesical  tenesmus,  incontinence,  con- 
stipation, but  seldom  incontinence  of  faeces)  are  pathogno- 
monic of  disease  of  the  lumbar  cord,  especially  of  tabes  and 
diffuse  myelitis.  Impotence  often  appears  early  in  locomotor 
ataxia. 

Impotence  is  also  a  symptom  of  diabetes  and  Bright's 
disease,  as  Avell  as  of  conditions  of  irritable  weakness  or 
exhaustion  in  neurasthenics. 

Of  less  diagnostic  importance  is  the  direct  mechanical  irritar 
bility  of  the  muscles,  which,  as  a  rule,  are  well  preserved. 

Paradoxicdl  contraction  of  Westphal,  wliich  occurs  among  other 
diseases  in  multiple  sclerosis,  paralysis  agitans,  has  been  up  to  this 
time  of  little  value.     It  consists  in  the  fact  that  when  the  foot  is 


in  disp:ases  of  the  nervous  system  57 

passively  flexed  dorsally,  it  will  remain  for  some  minutes  in  this 
position,  even  after  being  left  alone,  and  the  tendon  of  the  tibialis 
anticus  muscle  becomes  prominently  visible. 

The  Disturbances  of  Sensation 

The  diagnosis  of  every  disease  of  the  nervous  system  can 
only  be  completed  after  a  thorough  test  of  sensation.  Dis- 
turbances of  sensation  are  pathognomonic  of  many  diseases  of 
the  brain  and  spinal  cord ;  for  instance,  lesion  of  the  inter- 
nal capsule,  tabes,  syringomyelia,  neuritis.  In  many  other 
cases  the  extent  and  intensity  of  the  diseased  process  can 
only  be  determined  by  an  examination  of  the  sensation. 

We  designate  as  anmsthesia  the  loss  or  diminution  of 
sensation;  hyper cesthesia  the  increase  of  the  same  so  that 
very  weak  irritations  are  perceived  as  strong  ones.  Parces- 
thesias  are  abnormal  sensory  perceptions,  such  as  itching, 
crawling,  formication,  the  sensation  of  being  stroked  with 
fur,  etc.  Neuralgias  are  pains,  chiefly  paroxysmal,  in  the 
course  of  certain  nerves.  Pressure  points  are  those  points 
where  the  nerve  appears  directly  beneath  the  skin  or  on  the 
bone  which  are  especially  painful  on  pressure. 

The  neuralgias  are  special  affections,  as,  for  instance,  trigeminus 
neuralgia,  supraorbital  neuralgia,  sciatica. 

There  are  special  forms  of  neuralgia  v^^hich  recur  paroxysmally 
at  a  definite  period  of  the  day  and  which  are  occasioned  by  malarial 
infection  (malarial  neuralgia,  latent  intermittent)  ;  these  forms 
succumb  to  large  doses  of  quinine. 

A  complete  test  of  sensation  must  regard  the  various 
qualities  of  sensatioyi  of  which  each  may  be  tested  in  various 
ways  (partial  ansethesia). 

We  should  test  tactile  sense,  pain  sense,  space  sense, 
pressure  sense,  dynamic  sense,  muscular  and  articulation 
sense,  temperature  sense,  and  electro-cutaneous  sense. 

These  tests  should  be  made  at  vaiious  periods,  as  the  undivided 
attention  of  the  patient  is  necessary. 


58  DISEASES   OF   THE   NERVOUS   SYSTEM  chap. 

1.  Tactile  sense.  The  various  regions  of  the  skin  should  be 
touched  lightly  with  a  brush,  the  eyes  of  the  patient  should  be 
closed,  and  he  should  be  directed  to  say  "yes"  at  each  touch. 
In  some  cases,  especially  in  tabes,  the  answer  of  the  patient  may 
come  some  time  after  the  touch  (delayed  conduction). 

HypercBsthesia  in  the  extremities  occurs  among-  other  symptoms 
as  a  sign  of  neuritis ;  it  occurs  also  in  the  prodromal  stage  of  some 
acute  infectious  diseases,  as  in  typhoid,  for  instance,  and  during 
the  entire  course  of  meningitis. 

2.  Pain  sense  is  tested  by  pricking  with  a  pin,  by  pinching,  and 
wnth  strong  electric  currents.  Analgesia  is  the  lack  of  sensation 
(irrespective  of  the  ordinary  sense  of  touch)  to  the  usual  painful 
irritants,  such  as  the  prick  of  a  pin ;  it  occurs  in  hysteria,  tabes, 
and  peripheral  neuritis.  In  some  individual  cases  a  delayed  pain- 
ful sensation  may  be  demonstrated;  at  times  tactile  sensation  and 
pain  sensation  are  felt  one  after  the  other  {double  sensation). 

3.  Space  sense  or  sense  of  locality.  The  patient  should  be 
touched  and  he  should  immediately  indicate  the  spot  which  w^as 
touched  or  place  his  finger  upon  it.  The  examination  of  the  tactile 
distance  belongs  under  this  head.  It  is  determined  by  the  repeated 
application  of  a  compass  with  widely  opened  legs,  which  are  brought 
closer  and  closer  together  until  the  smallest  distance  apart  in 
which  they  are  felt  as  two  tactile  impressions  is  registered.  This 
distance  in  the  normal  individual  is  for  the 

Tip  of  tongue,  1  mm. 

Tip  of  finger,  2  mm. 

Mucous  surface  of  lip,  3  mm. 

Dorsal  surface  of  1st  and  2d  phalanges  and  inner  surface  of  finger, 

6  mm. 
Tip  of  nose,  7  mm. 

Thenar  and  hypothenar  eminences,  8  mm. 
Chin,  9  mm. 

Tip  of  large  toe,  cheeks,  and  eyelids,  12  mm. 
Heel,  22  mm. 
Dorsum  of  hand,  30  mm. 
lliroat,  35  mm. 

Forearm,  leg,  and  dorsum  of  foot,  10  mm. 
Back,  Goto  80  mm. 
Arm  and  tliigh,  80  mm. 

4.  Pressure  sense.  Considerable  disturbances  of  this  sense  are 
recognized  by  applying  various  strong  degrees  of  pressure  with  the 


ill  DISEASES   OF  THE   NEtlVOUS   SYSTEM  59 

finger,  slighter  disturljances  by  applying  various  heavy  weights 
upon  the  extremities,  which  ought  to  be  supported  upon  a  firm 
base.  Tlie  patient  should  mention  the  differences  between  the 
weights.  A  healthy  person  can  recognize  differences  of  one-tenth 
of  the  original  weight;  the  smallest  difference  appreciable  varies 
from  0.005  to  0.5  g. 

5.  Dynamic  sense  is  tested  by  lifting  in  the  hand  various  heavy 
weights  which  have  been  wrapped  in  a  cloth  and  estimating  their 
weights.  In  the  normal  person  the  dynamic  sense  is  finer  than 
the  pressure  sense. 

6.  Articulation  sense  and  muscle  sense.  By  means  of  these 
senses  the  position  of  each  limb  is  determined  with  closed  eyes.  It 
is  tested,  for  example,  by  flexing  the  fingers  of  the  patient  to 
smaller  and  larger  degrees  and  fixing  them,  when  the  patient  is  to 
recognize  the  various  degrees  of  excursions  or  flexions  with  closed 
eyes ;  or  the  leg  is  to  be  abducted  and  fixed  in  the  position  in 
which  the  slightest  degree  of  abduction  may  be  recognized  by  him. 
Disturbances  of  the  articulation  sense  may  be  demonstrated  in  all 
cases  where  there  is  an  interruption  of  the  sensory  conduction 
tracts,  particularly  in  tabes  and  neuritis,  mostly  before  the  gross 
ataxic  disturbances  become  distinct. 

7.  Temperature  sense.  The  skin  is  touched  with  dry  test  tubes 
or  metal  cylinders,  some  of  which  have  been  filled  with  cold  and 
some  with  warm  water.  In  health,  differences  of  J°  to  1°  C.  may 
be  detected  between  25°  and  35°  C.  marks  of  the  thermometer. 
Perverse  temperature  sense  is  the  term  given  to  the  disturbance  of 
sense  in  the  patient  who  recognizes  a  sensation  of  heat  when 
touched  with  ice.  Another  more  recent  test  of  the  temperature 
sense  consists  in  comparing,  in  the  various  regions  of  the  skin,  the 
absolute  temperature  sensibility  which  under  normal  conditions 
show  constant  fixed  local  differences  (Goldscheider). 

8.  Electro-cutaneous  sensibility.  A  faradic  current  is  applied 
with  a  wire  brush  and  the  figure  is  read  from  the  instrument  after 
the  secondary  coil  is  pulled  out  to  the  extent  at  which  the  current  is 
first  felt. 

EXAMIXATIOX    OF    ELECTRICAL    IRRITABILITY 

The  examination  of  the  electrical  irritability  of  paralyzed 
muscles  and  nerves  leads  to  important  conclusions  concern- 
ing the  location  of  the  disease,  but  especially  to  a  more 
definite  prognosis  of  the  duration  of  the  disease. 


60  DISEASES  OF  THE   NERVOUS   SYSTEM  chap. 

Method  and  normal  relations.  —  An  electrical  examination  is 
conducted  with  the  faradic  (induction)  and  with  the  galvanic 
(constant)  current.  The  indifferent  electrode  is  placed  upon  the 
sternum,  the  other  upon  the  muscle  or  nerve  to  be  examined. 
The  excitation  of  the  muscle  by  way  of  the  nerve  is  called  indirect 
irritation;  that  resulting"  from  the  direct  application  of  the  electrode 
to  the  muscle  itself,  direct  irritation.  The  examining  electrode  for 
determining  the  irritability  of  each  muscle  or  nerve  is  placed  upon 
certain  lixed  points  which  have  been  determined  empirically  and 
may  be  seen  in  Figs.  18  to  22. 

When  the  faradic  current  is  applied  by  direct  and  indirect  irri- 
tation, a  distinct  contraction  results.  The  distance  in  millimetres 
to  which  the  secondary  coil  is  moved  to  produce  the  slightest 
noticeable  contraction  is  then  read.  It  is  denoted  in  all  German 
books  as  R .  A .  —  mm . 

In  the  galvanic  examination  the  electrode  used  is  converted 
by  means  of  a  pole  changer  to  first  the  negative  (cathode,  zinc) 
pole,  then  to  the  positive  (anode,  carbon,  or  copper)  |>o/e.  On 
gradual  increase  of  the  strength  of  the  current  the  first 
weak  contraction  of  the  muscle  appears,  providing  the  cur- 
rent is  closed  in  such  a  manner  that  the  examining  electrode 
is  made  the  cathode  pole  (CaCc).  The  amount  of  current 
used  (determined  by  the  number  of  cells  used  or  by  the 
absolute  galvanometer)  is  then  registered.  With  this  amount 
of  current,  reaction  will  not  yet  appear  on  cathodal  open- 
ing, anodal  closure,  or  anodal  opening.  By  increasing  the 
strength  of  the  current  a  gradual  appearance  of  contraction 
will  appear  on  anodal  opening  (AnOc)  and  on  anodal  closure 
(AnCc) ;  only  with  a  much  stronger  current  than  this  will 
cathodal  opening  contraction  appear,  and  then  the  cathodal 
closure  contraction  will  already  have  been  tetanic.  The 
order  in  which  contractions  of  a  normal  muscle  takes  place 
by  increasing  strength  of  current  and  indirect  irritation  is, 
hence,  as  follows:^  1.  CaCC ;  2.  AnOC ;  .'l  AnCC ;  4.  CaCTe; 
5.  CaOC.     Contractions  are  short  and  lightning-like. 


1  The  followiiifi:  ahbrcviatioiis  are  in  use:  Ca  —  cathode ;  An  =  anode; 
C  =  closure  ;  O  =  opeuiug;  c  —  shght  coutractiuu  j  C  —  stroug  cun  traction  ; 
Te  =  tetanus. 


Ill 


DISEASES   OF  THE   NERVOUS   SYSTEM 


61 


Quantitative  change  of  electrical  irritability.  In  different 
diseases  the  electrical  irritability  of  the  nerves  and  muscles 
is  simply  increased  or  diminished  without  there  being  any 
change  in  the  order  or  in  the  quality  of  the  contractions. 


Branch  to  forehead 
and  eye. 

X.  flic,  (branch).  .^^ 

M.   retrahens  et   at 
tollens  auric. 

M.  occipitalis.   ^^ 

N.    auricul.     poster.     ^ 
prof.   (X.  facial.  I 

Branch  to  chin  and 
neck.  "" 

M.  splenius  cap.     ^. 

X.    access    Willissii. 
(Kam.  ext.) 

M.  sternocleidom.    -. 

M.  levat.  ang.   scap.     - 
M.  cucullaris.    _. 
Erb's     supraclavicu- 
lar point. 

X.  dorsalis  scap.    — 

X.   thor.   long.    (M. 
serrat  magnus). 

N.  axillaris. 

Plexus  brachialis. 

X.    thor.     aiit.     (M. 
pector.  major). 

X.  phrenicus. 


M.  frontalis. 

M.     corrugator     su- 
percil. 

-     51.  orbic.  palpebr. 

M.  pyramid,  nasi. 

Branch  to  nose  and 
mouth. 
•     il.  dilat.  narium. 

M.     zvgoniat.     (mi- 
nor [a],  maj.  [b].) 

M.  orbicularis. 
X.    pro     M.   triaijg. 
et  levat.  menti. 
•—  M.  triang.  menti. 

yU  levator  menti. 

M.  quadrat,  menti. 

'X.  subcut.  colli. 

-M.  platysm.  myoid, 
M.  sternohyoid. 
M.  omohyoideus. 

M.  sternothyreoid. 


Fig.  is. 


In  order  to  compare  the  results  of  examination  of  a 
unilateral  paralysis,  the  corresponding  nerves  and  muscles 
of  the  unaffected  side  should  be  tested  as  well.  In  bilateral 
paralysis  and  in  general  disease  of  the  nerves  a  comparison 
is  made  with  the  electrical  irritability  of  certain  nerves  as 
it  occurs  in  the  normal  person,  the  nerves  used  being  the 
frontal,  accessory,  ulnar,  peroneal  nerves. 


62 


DISEASES   OF   THE   NERVOUS   SYSTEM  chap. 


M.  lunibricales< 


M.  oppon.  digit,  miii 

M.  flexor  digit,  min 

M.  abd.  digit.  n)in 

M.  palniaris  brevis 

N.  uln.  (Ram.  vol.  prof 

X.  mediantis. 

M.     fle-^or    digit,    subl. 
ind.  and  mioim.). 

M.     flexor    digit,     subl 
(II.  and  III.) 

'W 

M.     flexor    digit,     prof.  "" 

M.ulnaris  int/rnus(flexor      ^  ~^^>^-/y. 

carp.  uln.).  """"■-"■•fciS^   ♦.'       \ 

M.  palm,  longus. 

ÄL  pronator  teres.    "•■•»•Jl^ '* 

i 

N.  medianus.    ;; /_%,.\    \  ;^' 

J      •  \!  \      \ 

N.  ulnaris.  /. 

M.  triceps    (Cap.    inter- ™ 

num). 


M.  abductor  poll. 

M.  flexor  poll,  brevis. 
M.  opponens  pollicis. 
AI.  abduct,  poll.  brev. 

M.  flexor  poll,  longus. 
M.  flexor  digit,  subl. 


M.   rad.   intern,  (flexor, 
carp.  rad. ). 


-—     M.  supin.  longus. 


..    M.  brachialis  intern. 

•"• M.  biceps  brachii. 

C N.  musculo-cutaneus. 


Fk;.  19. 


Ill 


Diseases  oi'  the  kervous  system 


(3.^ 


M.  intercss.  dors.  III. 
M.  inteross.  dors.  !!• 


>I.  inteross.  dors.  I.     --V-^t-» 


M.  ext-  poll,  brevis. 
M.  abd.  poll,  longus. 
M.  ext.  indicis  propr. 

M.  ulnaris  externus. 

M.  rad.  ext.  brevis. 


M.  rad.  ext.  longus. 

M.  supin.  longus. 

M.  brachialis  int. 

N.  radialis. 

M.  deltoideus. 


M.  inteross.  dors.  TV 
M.  abd.  digit,  niin. 


-  M.  ext.  poll,  longus. 
M.  ext.  indicis  propr. 


propr. 
M.  ext.  dig.  conitnun. 


■"-:---\,  ■  *~'^ M.ext.dig.niin. 

-4   ..    vim. 

•N§?. *"^-".!!ISi~    '    ^i-  supin.  brevis. 


»--k'CM.^. 


■  Cap.  ext. 


/f'.v^-;~5^.         'W''^^ ~  M.  triceps. 

■^^-  ^%,.        -^ 

'^V"    ^' ^^-  trie.  (Cap.  long.). 


Fig.  20. 


(U 


DISEASES   OF  THE   NERVOUS   SYSTEM 


CHAf. 


Electrical  irritability  is  simjib/  increased  especially  in 
tetaii}',  and  in  cases  of  recent  peripheral  lesions. 

Electrical  irritability  is  simj^Jy  diminished  in  all  paralysis 
of  long  standing  which  leads  to  muscular  atrophy,  as  in 
cerebral  hemorrhage,  bulbar  lesion,  cord  lesion  where  the 
trophic  centres  are  intact. 


?■< 


M.  gluteus  nia   . 
X.  glutseus 

X.  ischiadicus 
M.  abduct,  uiagn. 
M.  semitendinos. 


N.  tibialis 


M.  gastrocnemius 
M.  soleU'S 


M.  fle\.  digit,  conim. 

long. 
M.  fle\.  hallue.  long. 


N.  tibialis 


M.  biceps  fem.   (Caput  Ion- 
gum). 


M.  biceps  fem.  (Cap.  breve). 


—  X.  peroneus. 


Fk;.  21. 


Qualitative  change  of  the  electrical  irritability :  Degenera- 
tion reaction  (R.  D.).  Qualitative  change  of  the  electrical 
irritability  is  an  infallible  sign  of  paralysis  of  the  nerve 
periphercdly  ;  that  is,  in  cranial  nerves  the  gray  nuclei,  in 
spinal  nerves  the  ganglia  of  the  anterior  cornua  are  them- 
selves diseased  or  the  disease  lies  peripherally  to  these 
trophic  centres.     In  these  cases  the  fa  radio  and  galvanic 


in 


DISEASES   OF   THE   NERVOUS   SYSTEM 


65 


irritability  of  the  nerves  diminish  more  and  more  a  short 
time  after  the  beginning  of  the  paralysis.  In  8  to  10  days 
the  irritability  is  absolutely  lost;  no  contractions  are  to  be 
obtained  even  with  strong  currents.  The  direct  faradic 
irritability  of  the  muscles  is  also  abolished. 


Si 

3    ■ 

u 

V 

(5 


N.  cruralis 
M.  tensor  tasci«  latae» 

M.  sartorius 

M.  quadriceps  feni. 

M.  rectus  fern. 

M.  cruralis 

M.  vastus  ext. 
M.  vastus  int. 

M.  gastrocnemius 

M.  soleus. 

M.  flex,  halluc.  long. 

M.  abductor  dig.  min. 
M.  inteross.  dors. 


AI.  iidductor  magn. 
M.  adductor  lopg. 


1  ? 

J  I 


M.    extens.    dis 
comni.  long. 

M.  peron.  long. 


M.  peron.  hrev. 
M.    extens.    halluc. 
long. 


M.    extens.    dig. 
comni.  brevis. 


Fig.  22. 


On  the  other  hand,  the  direct  galvanic  irritability  of  the 
muscles  is  appreciably  increased  from  the  second  week ; 
contractions  result  even  with  the  weakest  currents.  The 
contractions  are  sloic,  long  continued,  and  vermicular.  The 
AnCC  follows  upon  the  CaCC  with  the  same  strength  of 
current,  and  is  often  stronger  than  the  CaCC ;  frequently 


ßQ  DISEASES   OF  THE   NERVOUS   SYSTEM  chap. 

CaOC  appears  sooner  than  AnOC  with  less  strong  currents 
(complete  degeneration  reaction). 

In  severe,  more  especially  in  incurable,  cases  the  galvanic 
muscular  irritability  diminishes  after  4  to  8  weeks'  dura- 
tion of  the  disease,  until  it  completely  disappears.  In  cur- 
able cases  the  conditions  of  electrical  irritability  become 
gradually  normal;  in  such  cases  the  power  of  voluntary 
movement  of  the  muscle  recovers,  however,  often  much 
sooner  than  the  electrical  irritability. 

Partial  degeneration  reaction,  which  permits  of  a  diagnosis 
of  paralysis  of  lighter  intensity,  consists  in  this,  that  fara- 
dic  and  galvanic  irritability  of  the  nerves  and  faradic  irri- 
tability of  the  muscles  are  only  slightly  lowered,  whereas 
the  distinguishing  characteristic  changes  on  direct  galvanic 
irritation  of  the  muscle  are  entirely  equal  to  each  other 
(see  p.  49). 

The  trophic  condition  of  the  paralyzed  muscles  is  in 
harmony  with  the  electrical  relation ;  disease  of  the  ganglia 
of  the  anterior  cornua,  as  well  as  of  the  nerves  peripheral 
to  these,  leads  to  degenerative  atrophy ;  disease  central  to  the 
trophic  centres  leads  only  gradually  to  slight  diminution  in 
bulk  of  the  paralyzed  muscles. 

Degeneration  reaction  occurs  in  peripheral  lesions  of  the 
motor  nerves  (traumatic  and  rheumatic,  diphtheritic,  toxic 
paralysis,  multiple  neuritis,  alcoholic  neuritis),  in  disease 
of  the  gray  anterior  cornua,  and  the  gray  nuclei  of  the 
medulla  (atrophic  palsies  of  children,  poliomyelitis). 

Degeneration  reaction  is  absent  in  all  cerebral  and  in  all 
spinal  paralyses  whose  origin  is  cephalad  to  the  trophic 
centres. 

Degeneration  reaction  is  of  prognostic  importance  in  this, 
that  either  irreparable  atrophy  of  the  affected  muscles  will 
ensue  or  that  recovery  can  only  at  best  begin  to  take  place 
in  2  or  3  months.  Absence  of  degeneration  reaction  is  a 
certain  diagnostic  sign  that  no  gross  anatomical  changes  have 


Ill  DISEASES   OF   THE   NERVOUS   SYSTEM  67 

taken  place ;  it  is  of  prognostic  value  in  that  it  denotes  that 
recovery  will  ensue  in  a  short  time,  often  in  3  to  4  weeks. 

Partial  degeneration  reaction  indicates  that  the  muscles 
have  suffered  serious  anatomical  changes,  whereas  the 
nerves  have  been  unaffected ;  it  admits,  therefore,  as  far  as 
time  is  concerned,  of  a  better  prognosis  than  complete 
degeneration  reaction. 

Symptoms  of  Some  of  the  Diseases  of  the  Nervous 

System 

Cerebral  palsies  have  been  spoken  of  sufficiently  in  the 
beginning  of  the  chapter  (see  p.  43  et  seq.). 

Cerebral  abscess  is  diagnosed  by :  (1)  the  etiology  (trauma, 
otitis,  embolism) ;  (2)  the  general  symptoms  (headache, 
vertigo,  vomiting),  varying  in  intensity;  (3)  the  irregular 
remissions  of  the  fever ;  (4)  the  absence  of  choked  disc ; 
(5)  the  focal  symptoms,  which  vary  according  to  the  site  of 
the  abscess,  although  they  may  be  entirely  absent. 

Tubercular  meningitis  is  diagnosed  when  :  (1)  other  organs 
are  demonstrated  to  be  the  seat  of  a  tuberculous  process ; 
(2)  the  fever  is  of  irregular  remittent  type ;  (3)  the  pulse  is 
slow  and  irregular ;  (4)  the  stupor  is  severe  and  associated 
with  delirium ;  (5)  the  neck  is  rigid,  there  is  vomiting,  and 
the  abdomen  is  retracted;  (6)  finally  tubercle  bacilli  in  the 
cerebro-spinal  fluid  obtained  by  lumbar  puncture  are  found. 

Cerebral  syphilis  may  be  diagnosed  from  the  following, 
if  proof  of  previous  syphilis  can  be  obtained :  there  are 
often  intense  prodromal  headaches,  epileptiform  convulsions, 
and  apoplectiform  attacks,  various  paralyses.  The  general 
signs  and  the  focal  symptoms  are  not  at  all  characteristic, 
for  the  same  may  be  present  in  tumor,  hemorrhage,  etc. 
In  all  doubtful  cases  mercurial  inunctions  should  be  given, 
which,  if  remedially  effective,  would  determine  the  diagnosis. 

Tumors  of  the  brain.  —  A  diagnosis  may  be  made  from  the 
following  data :    (1)  The  general  symptoms,  such  as  head- 


68  DISEASES   OF   THE   NERVOUS   SYSTEM  chap. 

aclie,  vertigo,  vomiting,  convulsions,  psychic  weakness,  are 
ushered  in  gradually,  and  increase  slowly  in  intensit}^ ; 
(2)  ophthalmoscopic  examination  reveals  choked  disc, 
though  an  absence  of  this  condition  does  not  disprove  the 
presence  of  a  tumor ;  (3)  there  are  focal  symptoms  which 
vary,  of  course,  according  to  the  region  of  the  brain,  which 
is  the  seat  of  the  growth. 

Progressive  bulbar  paralysis  is  accompanied  by  disturbance 
of  speech  (anarthria),  atrophy  of  the  tongue,  of  the  lips, 
and  of  the  muscles  of  mimicry  supplied  by  the  facial  nerve. 
Owing  to  this  paralysis,  the  face  appears  mask-like.  There 
is  difficulty  in  swallowing,  arising  from  the  atrophy  of  the 
pharyngeal  muscles.  Speech  is  weak,  and  its  tone  unvary- 
ing (monotone),  owing  to  atrophy  of  the  laryngeal  muscles ; 
coughing  becomes  impossible,  and  finally  respiratory  paraly- 
sis supervenes. 

Degeneration  of  the  combined  pyramidal  tracts  (manifested  by 
muscular  atrophy  and  increased  tendon  reflexes  in  the  upper  and 
spastic  paralysis  in  the  lower  extremities)  is  associated  with  de- 
generation of  the  nuclei  of  the  medulla.  This  condition  has  been 
recognized  by  a  few  authors  as  a  distinct  and  special  disease,  which 
they  call  amyotrophic  lateral  sclerosis. 

In  some  cases  bulljar  symptoms  are  associated  with  progressive 
spinal  muscular  atrophy  (see  below),  which  consists  of  a  degenera- 
tion of  the  anterior  cornua  and  the  anterior  nerve-roots. 

All  three  diseases  i)resent  a  degeneration  of  the  same  motor 
conducting  apparatus,  but  in  different  locations,  so  that  a  diag- 
nostic separation  in  many  cases  appears  artificial. 

Myelitis.  —  The  symptoms  vary  according  to  the  position 
of  the  process  in  the  cord. 

Myelitis  cervicalis  is  characterized  by  paraplegia  of  the 
legs,  paralysis  and  sensory  disturbances  in  both  arms. 
The  tendon  reflexes  are  increased,  and  spastic  phenomena 
are  present.     Tlie  bladder  and  rectum  are  affected. 

Myelitis  dorsalis  presents  essentially  the  same  symptoms, 
but  the  arms  are  wholly  unaffected. 


Ill  DISEASES   OF   THE   NERVOUS   SYSTEM  69 

Myelitis  lumhalis.  Paraplegia  of  both  legs,  but  the  upper 
extremities  are  unaffected.  The  bladder  and  the  rectum 
are  involved ;  the  skin  and  tendon  reflexes  are  diminished 
or  entirely  absent. 

As  a  special  form  of  clironic  iriyelitis,  there  have  been  described  : 
(1)  the  so-called  6;/?«.s7<c  .s/»m«Z  par«/y6'/.s'  (Erb,  CÄarcoQ,  characterized 
by  spastic  symptoms  in  the  extremities,  increased  reflexes  with  the 
preservation  of  the  bladder  and  sexual  functions,  and  said  to  de- 
pend wholly  on  lesion  of  the  pyramidal  tracts ;  and  (2)  progressive 
spinal  muscular  atrophy,  which  gradually  leads  to  degenerative 
atrophy  of  the  muscles  of  the  arm  and  shoulder,  and  which  is  due 
to  a  lesion  of  the  gray  anterior  cornua  and  anterior  roots. 

The  description  ot  poliomyelitis  (lesion  of  the  gray  substance  of 
the  cord)  belongs  to  this  category.  It  is  often  confounded  with 
multiple  neuritis,  and  its  diagnosis  is  made  with  great  difficulty. 
Poliomyelitis  can  only  be  diagnosed  with  certainty  when  it  occurs 
in  children,  where  it  is  known  as  the  essential  {spinal)  palsies  of 
children.  Here  the  age,  the  acute  onset,  the  subsequent  flaccid 
paralysis,  accompanied  with  atrophy  and  the  presence  of  degenera- 
tion reaction,  the  absence  of  reflexes,  and  the  preservation  of  sen- 
sation, will  establish  the  diagnosis. 

Tabes  dorsalis  is  diagnosed  by  the  iridoplegia,  the  loss  of 
tendon  reflexes,  lightning-like  pains  in  the  legs,  the  ataxia, 
the  Pomberg  symptom,  analgesia,  at  times  anaesthesia,  de- 
layed conduction,  and  parsesthesia.  In  some  cases  there  are 
periodical  disturbances  of  the  abdominal  viscera,  as,  for 
instance,  frequent  painful  attacks  of  vomiting  (crises  gas- 
triques).  The  presence  of  two  characteristic  symptoms 
(for  instance,  iridoplegia  and  failure  of  the  reflexes,  or 
iridopiegia  and  crises  gastriques)  will  render  the  diagnosis 
certain.  It  is  distinguished  by  three  stages  :  the  neuralgic, 
ataxic,  and  paraplegic. 

Multiple  sclerosis  of  the  brain  and  spinal  cord.  —  In  typical 
cases  there  is  intention  tremor,  scanning  speech,  nystagmus, 
spastic  paretic  gait,  increased  tendon  reflexes,  foot  clonus, 
and  gradually  developing  psychical  weakness.  Only  seldom 
do  we  find  all  signs  present  in  a  single  case. 


CHAPTER    IV 

DIAGNOSIS   OF   THE   DISEASES   OF  THE   DIGESTIVE 

SYSTEM 

Lips.  —  The  condition  of  the  nutrition  (see  p.  4)  of  the 
patient  and  the  state  of  the  blood  (see  p.  7)  are  deter- 
mined by  the  color  of  the  lips.  Dryness  of  the  lips,  and 
crusts  thereon,  indicate  a  febrile  disease.  In  typhoid,  the 
brown,  rusty  color  of  the  lips  (fuligo)  is  characteristic. 

Teeth.  —  A  healthy  person  has  moist  teeth.  Dry  teeth 
covered  with  sordes  indicate  neglect  and  fever.  A  good 
nurse  should  see  tliat  the  lips,  mouth,  and  teeth  of  every 
comatose  patient  are  kept  moist  and  clean. 

A  good  condition  of  the  teeth  insures  good  mastication. 
When  many  teeth  are  wanting,  the  food  is  swallowed  im- 
perfectly masticated ;  very  often  their  absence  serves  as  a 
guide  to  the  diagnosis  of  chronic  gastritis. 

The  age  of  children  may  readily  be  determined  by  the  number 
of  their  teeth,  and  especially  at  the  time  of  their  appearance.  A 
knowledge  of  the  period  of  the  eruption  of  the  teeth  is  necessary 
for  the  diagnosis  of  many  diseases  of  children. 

The  milk  teeth  are  twenty  (20)  in  number ;  on  each  side  above 
and  below,  two  (2)  incisors,  one  (1)  canine,  and  two  (2)  molars. 
They  appear  from  the  3d  month  to  the  3d  year  of  life,  usually  in 
the  following  order :  the  lower  central  incisors  from  the  3d  to 
the  loth  month  (average  7th  month),  the  upper  central  incisors 
from  the  9th  to  the  16th  month,  the  superior  lateral  incisors  from 
the  10th  to  the  Kith  month,  the  lower  lateral  from  the  13th  to  the 
17th  month.  The  first  four  molars  from  the  16th  to  the  21st 
month,  the  four  canines  from  the  16th  to  the  25th  month,  and  the 
four  second  molars  fi'om  the  23d  to  the  36th  month,  as  an  average, 
however,  between  the  24th  and  30th  months. 

70 


CHAP.  IV     DISEASES   OF  THE   DIGESTIVE   SYSTEM  71 

The  change  to  the  permanent  teeth  begins  in  the  7th  year  of 
life  and  proceeds,  as  a  rule,  in  the  same  order  as  does  first  denti- 
tion. The  third  molars  (wisdom  teeth)  appear  from  the  18th  to 
the  30th  years  of  life.  The  permanent  teeth  are  thirty -two  (32)  in 
number:  two  (2)  incisors,  one  (1)  canine,  two  (2)  bicuspids,  three 
(8)  molars  on  each  side  above  and  below. 

Tongue.  —  An  inspection  of  the  tongue  is  sanctioned  by 
old  custom  and  should  begin  the  examination  of  the  patient. 
The  tongue  of  the  healthy  is  bright  red  and  moist,  and  has 
no  tremor  when  extruded. 

In  febrile  diseases,  before  the  period  when  a  competent 
nurse  takes  charge,  the  tongue  is,  as  a  rule,  dry,  fissured, 
and  covered  with  discolored  fur.  Its  appearance  in  typhoid 
and  in  scarlet  fever  is  characteristic  ;  it  is  covered  with  a 
white  fur,  sometimes  brown,  and  with  a  red  stripe  on  either 
side  in  typhoid ;  it  has  the  strawberry  appearance  in  scarlet 
fever  (strawberry  tongue). 

In  non-febrile  conditions  the  tongue  should  be  examined 
to  see  if  it  be  bright  red  or  coated. 

A  normal  condition  of  the  tongue  in  these  respects  would 
in  most  cases  exclude  disease  of  the  stomach.  A  coated 
tongue  often  indicates  a  catarrhal  condition  of  the  gastric 
mucous  membrane.  Still  these  conditions  are  not  regularly 
united,  so  that  the  diagnostic  deductions  from  the  coated 
tongue  must  be  drawn  with  care.  It  should  be  borne  in 
mind  that  ulcer  of  the  stomach  (^idcus  ventrkuU)  and  hydro- 
chloric hyperacidity  are  usually  unaccompanied  by  a  coated 
tongue. 

Glossitis  or  inflammation  of  the  tongue,  attended  by  swelling  of 
and  intense  pain  in  this  organ,  is  an  infrequent  but  severe  infec- 
tious disease  which  requires  chiefly  surgical  treatment. 

Mouth.  —  Inflammation  of  the  mucous  membrane  of  the 
mouth  (stomatitis)  is  recognized  by  swelling  and  oedema  of 
the  mucous  membrane  which  is  exceedingly  painful.  It  is 
occasioned  chiefly  from  neglect  and  often  from  the  use  of 


72  DISEASES   OF   THE   DIGESTIVE   SYSTEM  chap. 

mercurials.      It  is  relieved  by  rinsing  the  mouth,  with  potas- 
sium chlorate. 

A  mild  form  of  stomatitis  not  infrequently  develops  after  a 
generous  consumption  of  grapes  such  as  is  ordered  in  "  a  grape 
cure." 

A  reddish  border  at  the  junction  of  the  g\uns  with  the 
teeth  occurs  often  and  has  no  diagnostic  significance ;  a 
grayish  or  bluish  border  is  produced  by  plumbic  sulphide 
and  indicates  plumbism  (lead  intoxication) ;  it  is  the  so- 
called  blue  line  of  the  gums. 

Soor  or  thrush  consists  of  small  grayish-white  mem- 
branous exudations  upon  the  buccal  mucous  membrane 
which  occur  in  weakly  children  often  after  neglect  and 
uncleanliness,  and  develop  in  the  adult  chiefly  toward  the 
end  of  some  severe  disease  (phthisis,  sepsis,  etc.).  (See 
Chap.  XII.)  The  cause  of  this  disease  is  a  fungus  (Saccha- 
romyces  or  Oidium  albicans)  which  grows  in  acid  media  in 
buds  and  in  alkaline  media  in  threads.  In  the  mouth  it 
grows  in  threads  and  round  conidia. 

Pharynx  and  tonsils.  —  (See  Chap.  V.,  Diagnosis  of  the 
diseases  of  the  upper  air-passages.) 

Saliva  is  an  alkaline  glandular  secretion  containing  mucin, 
whose  active  principle  is  diastase,  which  changes  starch  into  sugar. 
In  stomatitis  and  in  a  few  diseases,  such  as  diabetes,  the  saliva 
becomes  acid.  In  hyperacidity  of  the  stomach  the  diastatic 
activity  is  often  reduced.  Still,  thus  far,  the  examination  of  the 
saliva  has  not  attained  any  diagnostic  importance. 

Saliva  is  recognized  by  the  blood-red  color  obtained  by  adding 
an  acid  and  precipitating  with  ferric  chloride.  This  reaction 
depends  upon  the  presence  in  saliva  of  rhodanpotassium  (CXSK). 

(Esophagus 

Of  the  diseases  of  the  oesophagus  stricture  of  this  organ 
has  a  special  diagnostic  importance.  It  is  determined  by 
the  complaint  of  the  patient  that  the  bolus  of  food  sticks  in 


IV  DISEASES   OF   THE    DIGESTIVE   SYSTEM  73 

his  throat  or  before  it  reaches  his  stomach,  and  that  it  is 
often  regurgitated  and  tastes  very  badly. 

About  the  site  of  the  stricture  a  dilatation  is  produced  by  the 
pressure  of  the  accumulated  food,  in  -^'hich  decomposition  and 
fermentation  of  the  food  may  take  place.  The  retained  remnants 
of  food  are  regurgitated  after  a  while  by  the  retching  produced 
from  the  irritation.  We  can  recognize  that  these  remnants  never 
reached  the  stomach  by  the  fact  that  they  are  alkaline  in  reaction, 
owing  to  the  admixture  of  saliva,  and  where  milk  has  been  taken 
by  the  fact  that  it  is  not  coagulated. 

A  special  form  of  constriction  is  the  diverticular  (a  dilatation  of 
the  mucous  membrane  without  a  jjrimari/  stenosis) .  We  distinguish 
between  a  pressure  diverticulum  and  a  traction  diverticulum.  The 
former  is  always  situated  in  the  extra  thoracic  part  of  the  oesopha- 
gus, reaches  a  considerable  size,  varying  between  5  and  10  cm.,  so 
that  when  distended  it  may  be  seen  and  felt  on  the  outside  of  the 
neck  as  a  distinct  tumor.  This  form  of  diverticulum  may  shut 
oif  the  way  for  the  entrance  of  nutriment  and  thus  cause  death 
from  inanition.  It  is  produced  b}^  pressure  of  foreign  bodies, 
swallowing  too  large  masses  of  food,  and  by  traumatism.  The 
traction  diverticula  occur  in  the  lower  half  of  the  oesophagus,  and 
have  a  minimal  size  of  4  to  8  mm.  They  are  scarcely  ever  the 
object  of  medical  diagnosis.  They  are  produced  by  the  traction 
resulting  from  cicatricial  formation  ;  in  rare  cases  they  have  led  to 
pulmonary  gangrene  and  death  by  perforating  into  the  bronchi. 

The  diagnosis  of  oesophageal  stenosis  is  made  with  cer- 
tainty by  introducing  a  moderately  hard  oesophageal  sound 
of  ordinary  calibre.  Before  this  is  done  it  is  absolutely 
necessary  to  examine  in  each  case  whether  there  is  an  aortic 
aneurysm  present ;  should  such  be  the  fact,  no  attempts  at 
introducing  the  instrument  should  be  made.  Eecently 
success  has  been  attained  in  obtaining  a  view  of  the  interior 
of  the  oesophageal  tube  by  means  of  direct  oesophagoscopy 
{Rosenheim) ;  but  this  method  of  examination  is  too  diffi- 
cult to  admit  of  general  use. 

It  is  necessary  to  diagnose :  1.  The  seat  of  the  constriction, 
as  the  surgical  possibility  of  relief  will  be  thereby  deter- 
mined.     To  determine  this  point,  mark  the  place  on  the 


74  DISEASES   OF   THE   DIGESTIVE   SYSTEM  chap. 

oesophageal  sound  where  the  teeth  touch  it  after  the  con- 
striction has  been  reached,  and  after  the  instrument  has  been 
removed  measure  the  length  of  the  part  which  has  been  in- 
cluded between  these  two  points. 

The  distance  between  the  upper  incisor  teeth  and  the  cardia  of 
the  stomach  measures  in  adults,  as  a  rule,  40  cm.,  between  the 
incisors  and  the  beginning  of  the  Oesophagus  the  distance  is  15  cm., 
and  from  the  incisors  to  the  point  where  the  oesophagus  crosses  the 
bronchus  is  23  cm. 

2.  The  cause  of  the  constriction,  as  from  this  directly  depends  the 
prognosis  and  treatment.  The  most  frequent  cause  of  constriction 
is  carcinoma.  This  is  to  be  diagnosed  in  old  people,  especially  if 
they  emaciate  rapidly  and  have  a  cachectic  appearance,  if  there  be 
no  special  reasons  against  it. 

In  the  young  the  following  causes  may  occasion  the  stenosis : 
1.  Cicatricial  formatioJi,  (a)  the  result  of  an  extensive  burn  by 
acids  or  alkalies,  which  may  have  been  swallowed  accidentally  or 
with  suicidal  intent,  (6)  the  result  of  an  ulcer  of  the  cardiac  orifice 
of  the  stomach  or  of  the  oesophagus,  which  has  given  symptoms 
for  years  of  a  round  ulcer.  2.  Oesophagitis,  which  arises  from 
swallowing  a  foreign  body  or  from  the  extension  of  inflammation 
from  a  neighboring  pus  formation.  3.  Tumor  of  the  mediastinum 
or  aortic  aneurysm,  which  may  be  determined  by  the  physical  signs. 
4.  Cheesy  bronchial  glands  at  the  hilus  of  the  lungs,  which  may  be 
presumed  to  exist  when  tuberculosis  of  the  lungs  accompanies  the 
stenosis.  5.  Syphilis,  which  seldom  leads  to  oesophageal  stenosis, 
and  which  can  only  be  assumed  when  syphilis  is  shown  to  be 
present  and  when  every  other  etiological  factor  has  been  excluded. 
6.  Hysteria  in  the  young  should  cause  one  to  think  of  the  possi- 
bility of  a  nervous  spasm  of  the  cardia. 

The  diagnosis  is  only  completed  when  the  permeability 
and  the  calibre  of  the  stricture  are  determined ;  one  should 
try  to  pass  the  stenosis  with  carefully  repeated  applications 
of  sounds  of  varying  calibre.  The  proof  of  the  permeability 
of  the  stricture  is  not  always  to  be  found  in  the  descent  of 
the  sound,  for  that  may  be  occasioned  by  the  sound  bending 
upon  itself  in  a  diverticulum,  but  only  upon  hearing  the 
deglatitory  murmur  when  the  patient  is  asked  to  swallow. 


IV  DISEASES   OF  TUE   DIGESTIVE   SYSTEM  75 

This  sound  is  heard  011  auscultation :  1.  Posteriorly,  on  the  left 
side  next  to  the  vertebral  column  at  the  level  of  the  6th  dorsal 
vertebra;  it  is  a  short,  dull  murmur,  which  may  be  heard  immedi- 
ately after  the  act  of  swallowing.  In  stenosis  it  is  exceedingly 
weak,  and  in  closure  of  the  oesophagus  it  is  entirely  absent.  2.  An- 
teriorly, over  the  arch  of  the  ribs  on  the  left  side  next  to  the 
xiphoid  process.  Often,  in  addition  to  the  deglutitory  (primary) 
murmur,  another  (secondary)  murmur,  occurring  from  3  to  5 
seconds  later,  may  be  heard,  or  even  a  third;  these  secondary 
sounds  are  most  probably  produced  by  regurgitating  bubbles  of 
air.  In  stenosis  these  secondary  murmurs  are  heard  from  5  to  12 
seconds  later. 

Above  a  stenosis  and  over  diverticula,  loud  sounds,  at  times 
lasting  many  minutes,  may  be  heard  on  auscultation ;  they  arise 
from  the  motion  transmitted  by  muscular  action  to  the  fluids 
retained  in  the  diverticula. 

The  Diagnosis  of  the  Diseases  of  the  Stomach 

As  far  as  the  history  of  the  cases  is  concerned,  the  following 
points  are  to  be  regarded  :  — 

Hereditary  influences  have  seldom  an  important  bearing,  except 
for  carcinoma  and  neurasthenia.  The  patient's  mode  of  life,  how- 
ever, is  of  greatest  importance,  whether  he  has  been  exposed  to 
injurious  occupation  such  as  sedentary  work,  troubles  and  w^orries, 
psychical  emotions,  lead  intoxication,  etc.,  w-hether  he  was  guilty 
of  excesses  in  diet,  or  bolting  of  food,  or  of  chewing  his  food  im- 
perfectly, or  of  taking  his  food  too  hot,  whether  he  was  an  alco- 
holist  or  indulged  excessively  in  tobacco.  An  essential  point  to  be 
elicited  is  whether  he  became  emaciated  rapidly. 

The  next  step  is  to  investigate  accurately  the  complaints  of 
the  patient  concerning  the  signs  of  dyspepsia,  to  leave  nothing- 
omitted,  and  to  follow  with  an  inquiry  concerning  any  casual 
former  troubles  in  the  other  organs  (lungs,  heart,  and  kidneys). 

The  complaints  of  all  patients  with  gastric  affections,  and 
those  by  which  the  attention  of  the  physician  is  directed  to 
the  stomach,  refer  to  the  general  so-called  dyspeptic  symp- 
toms, viz.  loss  of  appetite,  eructations,  heart-burn,  pressure 
and  fnlness  in  the  region  of  the  stomach,  pain  in  that  organ, 
depression.     None  of  these  symptoms  in  itself  is  character- 


76  DISEASES   OF  THE   DIGESTIVE   SYSTEM         chap. 

istic  enough  to  justify  a  deliuite  diagnctsis  of  the  disease  of 
the  stomach.  It  is  of  special  diagnostic  value  that  the 
dyspeptic  symptoms  occur  also  in  the  course  of  diseases  of 
other  organs,  as,  for  instance,  in  the  inception  and  progress 
of  pulmonary  consumption  (phthisical  dyspepsia),  in  heart 
diseases  during  the  stage  of  compensatory  disturbance,  in 
nephritis,  in  attacks  of  gout,  in  diabetes. 

The  appetite  is  an  important  indication  of  health.  Loss  of  appe- 
tite is  a  sign  of  a  general  pathological  disturbance,  though  no 
special  deductions  may  be  drawn  from  it.  INIost  of  the  febrile  and 
chronic  diseases  are  accompanied  by  it.  The  special  forms  of  gas- 
tric diseases  which  begin  with  a  loss  of  appetite  are  gastritis  and 
carcinoma.  (Jastric  ulcer  and  hyperacidity,  on  the  other  hand,  are 
usually  associated  witli  a  good  appetite.  Still  numerous  exceptions 
occur.  Excessively  increased  appetite  (bulimia)  as  well  as  its  per- 
version, pathological  longings,  are  chiefly  the  signs  of  gastric 
neuroses,  although  they  sometimes  occur  in  other  affections. 

It  was  the  custom  to  regard  the  condition  of  the  appetite  as  an 
infallible  sign  of  either  good  or  bad  digestive  power ;  this  is,  how- 
ever, only  conditionally  true.  In  many  cases  even  a  poor  appetite 
may  be  associated  with  good  digestive  power. 

Eructation.  —  This  symptom  indicates  the  presence  of  fermenta- 
tion in  the  stomach ;  it  has  no  differential  diagnostic  significance. 

Frequent  loud  eructations,  spasmodic  in  character,  occur  in  neu- 
rasthenics as  a  result  of  swallowing  air ;  the  gas  discharged  is  with- 
out smell  and  tasteless;  chronic  pharyngitis  is  often  present  in  these 
cases. 

Pyrosis,  heart-burn,  acid  burning  in  the  oesophagus.  This  is 
almost  always  a  sign  of  an  increased  acidity  of  the  stomach.  Still 
no  diagnostic  deduction  should  be  made  from  its  presence,  because 
it  may  just  as  w^ell  indicate  an  excess  of  hydrochloric  acid  (anor- 
ganic hyperacidity),  a  severe  fermentation  which  appears  first  in 
cases  of  deficiency  of  hydrochloric  acid  (anorganic  anacidity),  and 
which  leads  to  the  formation  of  acetic  acid,  lactic  acid,  and  butyric 
acid  (anorganic  hyperacidity).  These  conditions  of  anorganic  and 
organic  hyperacidity  liave  different  prognostic  values,  and  rlemand, 
in  fact,  different  forms  of  diet  and  treatment,  notwithstanding  both 
may  present  the  same  symptom  of  pyrosis. 

Feeling  of  pressure  and  fulness  in  the  stomach.  This  symptom  is 
present  in  many  gastric  affections,  is  frequently  purely  a  neurotic 
symptom,  and  is  often  the  result  of  over-exertion. 


IV  DISEASES   OF   THE   DIGESTIVE   SYSTEM  77 

Pain  ill  the  stomach.  This  symptom  is  only  to  Ije  utilized 
with  the  greatest  care  in  making  a  differential  diagnosis. 
It  frequently  is  present  in  ulcer,  and,  on  the  other  hand,  in 
gastric  neuroses  and  catarrhs  as  well  as  in  carcinoma.  Only 
those  pains  which  are  confined  to  a  circumscribed  spot  and 
which  are  always  felt  in  that  spot  are  of  value  in  concluding 
that  there  is  a  gastric  ulcer.  (Localized  painful  points  are 
found  also  in  the  neuroses;  see  also  p.  81.) 

VOMITIXG 

Vomiting  results  when  the  centre  situated  in  the  medulla  oblon- 
gata is  irritated  and  at  the  same  time  the  abdominal  muscles  and  the 
diaphragm  are  contracted,  the  pylorus  is  closed,  the  cardia  is  open, 
and  when  probably  antiperistaltic  action  is  set  up  in  the  stomach. 
The  uritation  of  the  vomiting  centre  is  induced  either  directly  by 
the  blood  state,  as  appears  when  emetics  are  taken,  by  swallowing 
caustic  materials  such  as  acids  and  alkalies,  or  b}''  poisons  such  as 
chloroform  and  morphia,  or  by  toxic  disease-products  as  in  chronic 
nephritis,  urcemia,  and  cholera,  or  by  reflex  irritation.  Reflex  vom- 
iting may  arise  from  various  organs ;  from  the  hraiyi  in  meningitis 
and  tumor  cerebri,  from  the  peritoneum  in  peritonitis  and  appendi- 
citis, from  the  kidneys  in  renal  colic  and  pyelitis,  from  the  bladder 
in  stone,  from  the  genital  organs  in  endometritis  and  pregnancy,  or 
from  the  stomach  as  in  several  diseases  of  that  organ.  The  ten- 
dency to  vomit  in  heai^t  disease  is  chiefly  induced  by  congestion  gas- 
tritis, though  often  acute  cardiac  dilatation  (for  instance,  induced 
by  over-exertion)  as  well  as  cardiac  failure  are  accompanied  by  it. 

Vomiting  may  also  result  from  psychic  influences,  especially  from 
disgust.     Many  persons  are  nauseated  from  fright  and  fear. 

Eepeated  vomiting  is  a  sign  of  various  visceral  disorders. 
It  is  pathognomonic  for  meningitis,  peritonitis,  and  uraemia. 
In  Bright's  disease  it  is  an  evil  omen,  as  it  is  early  indication 
of  ensuing  ursemia.  Its  frequency  is  for  a  great  part  a  deter- 
mining prognostic  feature  of  meningitis.  Pregnancy  is  often 
first  diagnosticated  by  the  presence  of  persistent  vomiting, 
especially  when  the  vomiting  occurs  with  an  empty  stom- 
ach ;    a   special   prognostic   and  very  serious    symptom  is 


78  DISEASES   OF   THE   DIGESTIVE   SYSTEM         cUai*. 

offered  by  the  intractable  vomiting  of  pregnancy,  which 
often  may  be  the  indication  for  the  artificial  production  of 
premature  labor. 

Repeated  vomiting  m.  febrile  disorders  demands  special  diagnos- 
tic attention.  There  may  be  prodromal  vomiting,  as  occurs  in  scarlet 
fever  and  erysipelas.  It  may  serve  as  an  essential  symptom  of  dis- 
ease, as  in  meningitis  and  peritonitis.  It  may  be  caused  by  drugs, 
e.g.,  antipyrin,  or  by  defective  nutritive  materials.  Its  most  severe 
form  is  associated  with  "  irritative  exhaustion  "  and  is  then  often 
accompanied  by  singultus,  which  are  chiefly  features  of  the  remis- 
sion of  the  disease,  or  of  a  beginning  convalescence. 

Periodical  recurreyit  attacks  of  frequent  vomiting  which 
alternate  with  periods  of  freedom  therefrom  have  a  special 
diagnostic  importance :  they  are  the  so-called  gastric  crises, 
and  are  associated  with  distressing,  often  unbearable  nausea. 
They  may  last  for  days  and  frequently  lead  to  inanition. 
They  appear  in  diseases  of  the  spinal  cord,  esx^ecially  in 
tabes  dorsalis.  Not  infrequently  this  characteristic  group 
of  symptoms  may  be  the  first  sign  which  calls  attention  to 
the  existing  tabes  which  may  have  previously  been  over- 
looked. Still  periodical  recurrent  vomiting  may  be  a  sign 
of  a  neurasthenic  gastric  disorder  without  having  a  central 
origin,  but  in  each  of  the  latter  cases  it  is  wise  to  enter- 
tain a  suspicion  of  its  being  of  central  origin. 

From  vomiting  alone  no  diagnosis  of  disease  of  the  stom- 
ach should  be  made ;  there  should  be  a  further  examination 
to  determine  whether  any  of  the  following  described  signs 
are  present. 

Vomiting  in  diseases  of  the  stomach.  Repeated  vomiting 
occurs  in  so  many  gastric  disorders  (e.g.,  ulcer  of  the  stom- 
ach, gastritis,  dilatation  of  the  stomach,  carcinoma,  gastric 
neurosis)  that  from  this  sign  alone  no  diagnosis  is  possible. 

Composition  of  the  vomited  material.  The  vomited  matter  is  com- 
posed chiefly  of  particles  of  food  which  have  been  much  changed 
by  the  gastric  juice  and  by  fermentation  in  the  stomach   (these 


IV  DISEASES   OF  THE   DIGESTIVE   SYSTEM  79 

changes  produce  from  the  caiboliydrate*:,  lactic  acid,  hiityric  acid, 
and  acetic  acid  ;  from  the  fats,  free  fatty  acids ;  from  the  albu- 
minoids, leucin,  and  tyrosin  in  addition  to  the  peptones) ;  saliva 
(especially  present  in  matutinal  vomiting)  ;  mucus  (in  g^istritis, 
but  not  diagnostic)  ;  bile  (with  no  diagnostic  significance,  yet  it 
indicates  always  that  the  pylorus  is  permeable)  ;  urea  (in  ursemia  ; 
concerning  its  demonstration,  see  Chap.  YIII.). 

Microscopic  examination  of  the  vomited  material.  Under  the  mi- 
croscope we  find  particles  of  food  (striped  muscular  fibres,  fat 
globules,  starch  cells,  and  vegetable  fibres),  pavement  epithelium, 
which  comes  from  the  mouth  and  oesophagus,  leucocytes,  various 
forms  of  bacilli  and  cocci,  fungus,  and  sarcina.  An  abundance  of 
sarcina  indicates  a  considerable  fermentation  in  a  dilated  stomach, 
though  it  gives  no  indication  as  to  the  cause  of  the  dilatation. 

On  tlie  otlier  hand,  special  kinds  of  vomiting  are  pathog- 
nomonic. 

1.  Vomiting  of  blood  (Jicematemesis,  melcena)  is  pathogno- 
monic of :  a.  Ulcer  of  the  stomach,  when  the  vomited  mat- 
ter is  composed  of  fresh,  dark-red,  inodorous  blood ;  it  also 
occurs  in  cirrhosis  of  the  liver,  b.  Vomiting  of  old,  decom- 
posed, sometimes  badly  smelling  blood  (coffee-ground  vomit) 
is  pathognomonic  of  carcinoma. 

Blood  is  sometimes  vomited  when  the  gastric  mucous  membrane 
is  inflamed  by  irritating  substances,  such  as  acids  and  alkalies.  In 
haemophilia  blood  may  be  vomited  without  an  essential  cause. 
Hysterical  women  in  rare  cases  have  haematemesis.  In  young 
girls  vomiting  of  blood  at  the  time  of  a  suppression  of  the  men- 
strual flow  is  of  no  serious  consequence  (vicarious  haematemesis). 
Still  one  should  always  examine  carefully  for  ulcer  of  the  stomach. 

One  should  be  on  the  watch  to  distinguish  between  vomiting  of 
blood  and  coughing  of  blood.  In  the  majority  of  cases  patients 
will  describe  characteristically  either  hfematemesis  or  haemoptysis. 
But  sometimes  coughing  is  attended  by  retching,  and  sometimes 
blood  which  lias  been  coughed  up  is  swallowed.  In  some  cases 
haemoptysis  or  haematemesis  is  the  first  sign  of  a  pulmonary  or 
of  a  gastric  disorder  which  may  have  been  concealed  until  the 
appearance  of  this  sign  startles  the  patient  to  the  highest  degree 
so  that  he  cannot  describe  accurately  the  manner  in  which  it  ap- 
peared.    In  such  cases  (seldom  occurring)  it  may  be  much  more 


80 


DISEASES   OF   THE    DIGESTIVE    SYSTEM 


CHAP. 


difficult  to  establisli  a  diiferential  diagnosis  than  in  cases  of  fresh 
bleeding,  where  it  should  be  always  a  rule  to  exercise  the  greatest 
care  in  cond acting  the  examination  of  the  organ,,  or  to  postpone  it  until 
.all  hcemo7Thage  has  ceased  /or  some  time. 


Plant  cell 


Sarcina  ventriciili.     -J, 


Muscle  fibres. 


roörgaiiisins.     Epithelial 
cells. 


Yeast. 
Fig.  23.  —  Schematic  Microscopic  Picture  of  Vomitus. 


2.  Fmcal  vomiting  (iniserere)  is  the  sign  of  intestinal 
obstruction  (ileus)  (see  p.  95.) 

3.  Very  copious  vomiting  appearing  after  long  intervals 
of  time  is  characteristic  of  dilatation  of  the  stomach. 

In  a  dilated  stomach  the  food  accumulates,  owing  to  the  atony 
of  the  walls  or  to  the  inability  to  pass  into  the  pylorus  on  account 
of  mechanical  obstacles.  As  soon  as  the  stomach  is  over-distended 
by  reason  of  the  continuous  ingestion  of  food,  it  gets  rid  of  a  part 
of  its  contents  by  the  vomiting  of  1  or  2  litres  of  often  decomposed 
fermented  material.  After  this  the  patient  feels  better,  eats  for 
several  days  with  steadily  increasing  discomfort  until  finally  very 
copious  vomiting  begins  anew. 

4.  Matutinal  vomiti)ig  or  morning  vomiting  before  break- 
fast, accompanied  l)y  intense  nausea  and  composed  mostly 


IV  ,  DISEASES   OF   TUE    DIGESTIVE    SYSTEM  81 

of  imu'us  and  only  seldom  of  cleur  fiiiid,  is  produced  by  a 
pharyngitis  such  as  is  most  frequently  found  combined  with 
an  alcoholic  gastritis  (yomitas  matut  In  us  potato  rani). 

5.  Vomiting  iniinediately  after  eating,  chiefly  attended  by 
nausea,  is  characteristic  of  hysterical  or  nervous  dyspep»sia. 
In  such  cases  one  should  look  always  for  other  signs  of 
neurasthenia. 

In  most  cases  it  is  not  possible  to  make  a  definite  diag- 
nosis from  the  character  of  the  complaints  of  the  dyspep- 
tics.   Under  these  circumstances  it  is  necessary  to  obtain  an 

Objective  Examination  of  the  Stomach 

The  estimation  of  the  general  condition  of  the  patient  is  of  the 
greatest  value.  Rapid  loss  of  strength  would  indicate  a  gastric 
carcinoma,  whereas  a  good  appearance  would  contra-indicate  it ; 
still  extensive  emaciation  may  accompany  chronic  gastric  catarrh 
and  dilatation  of  the  stomach.  One  should  notice  the  attitude  of 
the  patient,  the  character  of  his  complaints,  the  expression  of  his 
face  and  of  his  eyes  in  order  to  discover  whether  he  is  of  nervous 
temperament. 

Inspection  is  generally  of  little  value.  Only  in  cases  of  consid- 
erable dilatation  does  the  stomach  appear  as  a  distended  bladder 
extruding  the  thin  abdominal  wall. 

Palpation.  —  On  palpation  one  should  be  on  the  watch  for 

1.  Tenderness,  which  accompanies  many  of  these  disorders. 
Only  severe  localized  pain  which  is  increased  on  pressure  would 
indicate  ulcer. 

The  pain  of  ulcer  of  the  stomach  is  especially  characterized  by 
the  fact  that  it  is  produced  by  the  contact  of  the  ulcer  with  the  acid 
contents  of  the  stomach  and  increases  after  food  has  been  taken. 
^Vhen  the  stomach  is  free  from  food  in  cases  of  ulcer,  the  patients 
are  as  a  rule  free  from  pain.  The  pain  begins  soon  after  eating, 
increases  gradually,  and  reaches  its  highest  point  from  2  to  3 
hours  after  the  introduction  of  food.  Yomitinq;  the  acid  stomach 
contents  produces  a  diminution  of  the  pain.  It  is  often  possible 
to  determine  the  location  of  the  ulcer  from  the  pain,  which  changes 
with  different  positions  of  the  body ;  patients  with  an  ulcer  of  the 
pylorus  are  relieved  of  pain  by  lying  on  the  left  side,  an  act  which 
takes  the  food  away  from  the  pyloric  end;    should  the  pain  be 


82  DISEASES   OF   THE    DIGESTIVE    SYSTEM  chap. 

situated  on  the  posterior  wall  of  the  stomach,  an  abdominal  post- 
ure will  relieve  it.  Ulcer  of  the  duodenum  is  recognized  by  the 
fact  that  the  pain  begins  only  afle?'  the  food  contents  have  passed 
into  the  small  intestine  in  from  2  to  3  hours  after  ingestion. 

2.  The  2^Tesence  of  a  tumor.  Only  when  a  tumor  can  be 
felt  ought  we  make  a  diagnosis  of  carcinoma.  Tumors  of 
the  stomach  move  only  slightly  on  respiration,  whereas 
hepatic  tumors  move  up  and  down  distinctly.  Should  no 
tumor  be  felt  when  cancer  is  supposed  to  exist,  then  the 
diagnosis  of  carcinoma  should  be  made  tentatively ;  for  one 
may  be  present  on  the  posterior  wall  which  can  not  be  felt 
by  palpation. 

Tumors  of  the  stomach  are  mostly  carcinoma  when  they  occur 
in  old  people.  Still,  there  are  practically  many  important  excep- 
tions, as  :  1.  hypertrophy  of  the  pylorus,  which  may  feel  like  a  tumor 
about  the  size  of  a  pigeon's  egg.  The  diagnosis  of  this  disorder  is 
confirmed  by  the  presence  of  the  signs  of  ulcer,  the  long  duration 
of  the  symptoms,  the,  as  a  rule,  good  preservation  of  the  body,  and 
the  failure  of  the  tumor  to  grow  in  size.  Still,  when  accompanied 
by  an  extensive  dilatation,  the  differential  diagnosis  may  be  most 
difficult.  2.  Perigastritis  in  chronic  gastric  ulcer.  Chronic  ulcer 
of  the  stomach  leads  frequently  to  a  diffuse  infiltration  and  thick- 
ening of  the  tissues  about  the  ulcer,  which  may  give  rise  on  palpa- 
tion to  the  sensation  of  a  tumor.  Here,  also,  a  fairly  well  nourished 
condition  of  the  body,  the  long  duration  of  the  disease,  the  pre- 
ceding symptoms  of  ulcer,  and  the  structure  (consistency)  of  the 
tumor  may  lead  to  the  diagnosis. 

Percussion.  —  By  its  means  the  size  of  the  stomach  is 
determined,  though  simple  percussion,  as  a  rule,  gives  un- 
trustworthy results,  because  the  surrounding  intestines  give 
rise  to  the  same  percussion  note  (Fig.  24). 

The  stomach  is  so  situated  in  the  abdominal  cavity  that  |  of  its 
volume  lie  on  the  left  side  of  the  median  line,  while  \  is  on  the 
right  of  that  line.  The  fundus  lies  in  the  concavity  of  the  left 
vault  of  the  diaphragm,  the  cardia  at  the  level  of  the  11th  to  12th 
dorsal  vertebra;  the  small  curvature  and  the  pylorus  are  covered 
by  the  liver.     The  pylorus  is  situated  on  the  right  sternal  line  at  the 


IV 


diseAvSp:s  of  the  digestive  system 


level  of  the  apex  of  the  xiphoid  process.  The  lower  limits  of  the 
stomach  extend  to  from  2  to  3  finger  breadths  above  the  umbilicus. 
The  space,  within  which  the  tympanitic  note  of  the  stomach  is 
heard,  over  the  thoracic  wall,  is  called  the  semilunar  space ;  the 
boundaries  of  the  semilunar  space  are  liver,  lung,  spleen,  and  arch 
of  the  ribs. 


Fig.  24. — Eelative  Position  of  Stomach,  Liver,  amj)  Colon. 


Valuable  results  are  obtained  by  percussing  the  stomach 
when,  after  its  being  empty,  several  glasses  of  water  are 
taken  one  after  the  other  during  definite  intervals.  In  such 
a  case,  on  percussing,  a  gradually  increasing  area  of  dulness 
is  obtained  corresponding  to  the  drinking  of  each  glass  and 
by  which  the  lower  border  of  the  stomach  may  be  distinctly 
recognized. 


84  DISEASES   OF   THE    DIGESTIVE    SYSTEM  chap. 

The  most  reliable  re.sults  in  reference  to  determining  the 
size  of  the  stomach  are  to  be  obtained  by 

Ballooxixg  the  Stomach 

This  ought  to  be  done  in  all  cases  in  which  a  suspicion  of 
a  dilatation  of  the  stomach  is  entertained.  Should  there  be  a 
suspicion  of  the  presence  of  an  ulcer,  distending  the  stomach 
with  gas  should  not  be  performed,  as  it  would  be  extremely 
hazardous. 

The  operation  is  performed  by  administering  to  the  patient 
when  the  stomach  is  empty  a  teaspoonful  of  tartaric  acid,  and  fol- 
lowing this  with  the  administration  of  a  teaspoonful  of  sodium 
bicarbonate  dissolved  in  a  little  water.  Carbonic  acid  gas  is  thus 
generated  within  the  stomach,  and  as  a  result  the  contours  of  the 
stomach  in  many  cases  become  distinctly  visible  within  the  abdom- 
inal wall.  In  other  cases  where  the  stomach  is  not  thus  forced 
out  so  visibly,  percussion  of  the  organ  easily  differentiates  it  from 
the  surrounding  viscera.  Should  the  disease  be  one  which  would 
indicate  the  introduction  of  a  stomach-tube,  the  stomach  may  be 
directly  blown  up  by  the  carefvil  use  of  an  air-pump. 

The  stomach  is  the  seat  of  dilatation  when  its  lower 
border  reaches  the  umbilicus. 

It  should  be  observed,  however,  that  there  are  many  people  who 
have  naturally  an  unusually  large  stomach,  which,  nevertheless, 
performs  its  functions  well  (megalograstia) .  Dilatation  of  the 
stomach  only  refers  to  those  cases  of  gastric  enlargement  which  are 
produced  by  pathological  causes  and  which  give  rise  to  disease 
symptoms.  A  descent  of  the  lower  border  of  the  stomach  m^y 
be  produced  by  a  dislocation  of  the  entire  organ ;  in  these  cases 
the  transverse  colon,  as  a  rule,  is  also  shoved  downwards  and  the 
other  abdominal  viscera,  such  as  the  kidneys,  are  displaced,  owing 
to  the  relaxation  of  the  peritoneal  folds  {enteroptosis,  Glenard's 
disease) . 

Recently  the  size  of  the  stomach  lias  been  determined  by  the 
introduction  into  the  organ  of  an  electric  light,  which  illuminates 
it  so  that  its  contours  may  be  mapped  out  (gastrodiaphany).  This 
method  has  also  been  used  for  diagnosing  tlie  presence  of  a  tumor 


IV  DISEASES   OF   THE   DIGESTIVE   SYSTEM  85 

of  the  stomach,    its  use,  however,  necessitates  an  expensive  instru- 
ment and  a  very  strong  electric  current. 

l^y  the  use  of  these  methods  of  examination  a  differential 
diagnosis  may  be  made  in  very  many  cases. 

In  several  cases  the  determination  of  a  diagnosis  offers 
many  data  for  the  necessary  therapeusis  ;  e.g.,  ulcer  and 
dilatation.  In  a  large  class  of  cases,  nevertheless,  the  treat- 
ment depends  on  the  cause  of  the  conditions  of  the  acidity 
of  the  stomach.  An  anatomical  diagnosis  can  only  deter- 
mine this  in  a  few  cases,  because  many  cases  of  the  same 
form  of  disease  must  be  treated  differently  according  as  the 
acidity  of  the  gastric  juices  varies. 

The  treatment  of  many  diseases  of  the  stomach,  especially  of 
catarrhs  and  neuroses,  is  chiefly  a  dietetic  one.  But  the  regulation 
of  the  diet  is  directly  dependent  upon  the  conditions  of  acidity. 
Patients  with  a  hydrochloric  hyperacidity  bear  meat  extremely 
well,  milk  also  in  most  cases,  but  digest  the  carbohydrates  badly 
and  only  partially  the  fats.  Patients  with  an  anacidity  digest 
fat  and  carbohydrates  well  as  a  rule  if  fermentation  is  checked, 
whereas  meat  in  large  quantities  distresses  them  easily.  The 
medicinal  treatment  —  whether  it  should  be  an  acid  or  an  alkali 
—  is.  directly  dependent  on  the  knowledge  of  the  acidity  of  the 
stomach.  Finally,  the  indications  for  washing  out  the  stomach 
may  only  be  first  determined  by  an  examination  of  the  stomach 
contents,  as,  for  instance,  in  organic  hyperacidity. 

In  all  those  cases  where  the  anatomical  diagnosis  presents 
no  sufficient  data  for  the  selection  of  a  mode  of  treatment, 
we  should  undertake 

The  Analysis  of  the  Contents  of  the  Stomach 

MetJwds  and  normal  relation.  In  the  morning,  when  the  stomach 
is  entirely  empty,  a  soft  stomach-tube  should  be  introduced,  and  by 
means  of  a  small  aspirating  bottle  some  of  the  contents  is  aspir- 
ated. The  healthy  stomach  before  breakfast  contains  nothing  or 
but  a  little  slightly  acid  fluid.  Accordingly  the  patient  should  be 
instructed  to  drink  a  pint  of  milk  and  to  eat  some  bread  (milk  test 
meal).      Two  hours  thereafter  the  stomach-tube  is  again  intro- 


86  DISEASES  OF   THE   DIGESTIVE   SYSTEM         chap. 

duced,  and  the  contents  of  the  stomach  are  aspirated.  These 
should  be  filtered,  and  the  filtered  solution  examined  as  to  its 
acidity.  The  introduction  of  the  tube  is  easily  done  without  much 
trouble  to  the  patient;  still,  a  certain  skill  is  required  in  intro- 
ducing it  which  may  be  acquired  by  practice.  Should  the  retching 
which  follows  the  attempt  at  introduction  be  excessive,  a  10  per 
cent,  solution  of  cocaine  may  be  applied  by  a  brush  to  the  pharynx 
about  10  minutes  before  operating.  Introducing  a  tube  in  an 
empty  stomach  is  not  necessary  in  all  cases,  but  is  a  desirable  pro- 
cedure in  cases  of  hyperacidity. 

Instead  of  the  milk  test  meal,  the  patient  may  take  :  1.  Etvald's 
test  meal,  composed  of  a  roll  and  a  cup  of  tea.  This  should  be 
aspirated  from  the  stomach  for  test  purposes  in  three-quarters  of 
an  hour.  2.  The  Leube-Riegel  test  meal,  which  consists  of  barley- 
soup,  150  to  200  grammes  of  beefsteak,  50  grammes  of  bread 
and  a  glass  of  water,  aspirated  in  4  to  5  hours.  3.  Should  an 
accurate  determination  of  whether  lactic  acid  is  formed  in  the 
stomach  be  required,  it  is  best  to  use  Boas' s  suggestion  of  giving, 
the  night  before  the  stomach  is  to  be  aspirated,  a  meal  composed 
of  oatmeal  (1  tablespoonful  of  oatmeal,  1  teaspoonful  of  salt,  and 
1  quart  of  water,  boiled  together).  The  following  morning  an 
aspiration  of  the  stomach  should  be  made. 

Instead  of  aspirating  we  may  gain  sufficient  of  the  stomach 
contents  by  pressing  upon  the  epigastrium,  and  having  the  patient 
at  the  same  time  attempt  to  vomit  {EivahUs  expression  method). 

The  contents  are  filtered  and  the  filtered  solution  is  examined  :  — 

1.  With  litmus  paper. 

2.  For  Jree  acid.  Pour  a  few  drops  of  a  watery  solution  of 
methyl-violet  into  a  watch  glass  full  of  the  stomach  contents.  If  but 
a  little  hydrochloric  acid  be  present,  the  solution  becomes  slightly 
blue.  Another  test  is  to  add  a  few  drops  of  a  weak  solution  of 
yellow  tropäolin  ;  in  the  presence  of  free  HCl  the  solution  becomes 
more  or  less  red.  A  third  test  is  with  Giinzhurffs  solution,  com- 
posed of  phloroglucin,  2  grammes;  vanillin,  1  gramme;  absolute 
alcohol,  30  grammes  (to  be  preserved  in  a  dark  bottle),  of  which 
one  drop  is  added  to  several  of  the  gastric  fluid  in  a  porcelain  dish 
which  is  put  over  a  Bunsen  burner  and  slightly  warmed ;  if  there 
be  any  hydrochloric  acid  present,  red  streaks  composed  of  the 
finest  crystals  develop. 

3.  For  lactic  acid  with  Uß'elmann's  solution,  which  is  composed 
of  10  c.c.  of  a  1  per  cent,  solution  of  carbolic  acid,  1  to  2  drops 
of   iron  Perchlorate,  which    makes  a  blue-violet  color.      To  this 


IV  diseases' OF   THE   DIGESTIVE    SYSTEM  87 

reagent,  which  may  be  placed  in  a  test  tube,  a  few  drops  of  the 
gastric  fluid  are  added  ;  if  a  large  quantity  of  lactic  acid  be  present, 
the  fluid  becomes  yellow.  In  the  presence  of  a  large  quantity  of 
hydrochloric  acid  tliis  test  will  fail,  so  that  it  would  be  necessary 
to  shake  10  c.c.  of  gastric  fluid  and  50  c.c.  of  ether  in  order  to 
obtain  the  lactic  acid. 

4.  For  peptone  with  the  biuret  reaction ;  a  specimen  of  gastric 
fluid  is  rendered  strongly  alkaline  with  sodium  hydrate,  a  1  jjer 
cent,  cupric  sulphate  solution  is  added  drop  by  drop,  and  if  pep- 
tone be  present  a  distinct  red  color  Avill  appear. 

5.  It  is  necessary  to  determine  the  total  acidity.  For  this  purpose 
10  c.c.  of  gastric  fluid  are  titrated  with  deci-normal  sodium  hydrate 
solution.  It  is  advisable  to  use  a  graduated  burette,  from  which 
the  deci-normal  sodium  hj'drate  solution  may  be  dropped,  and  a 
pipette  with  which  10  c.c.  of  gastric  fluid  may  be  put  into  a  glass 
beaker.  The  gastric  fluid  in  the  beaker  is  diluted  with  distilled 
water  until  it  is  nearly  colorless,  and  2  drops  of  an  alcoholic 
solution  of  phenolphtalein  are  added.  This  solution  becomes  red 
in  alkaline  solutions,  while  it  remains  colorless  in  neutral  and  acid 
solutions.  After  this,  one  should  carefully  drop  from  the  burette 
the  sodium  hydrate  solution  into  the  diluted  gastric  fluid  until  the 
mixture  becomes  of  a  faint  rose  tint.  The  amount  of  deci-normal 
sodium  hydrate  used  indicates  the  amount  of  acid  the  stomach 
fluid  contained ;  for  example,  to  produce  the  rose  tint  in  the  10  c.c. 
of  gastric  fluid  5.8  c.c.  of  sodium  hydrate  were  used ;  therefore  in 
100  c.c.  of  gastric  fluid  58  c.c.  would  have  been  used ;  the  total  acidity 
is  hence  58.  But  since  1  c.c.  of  deci-normal  sodium  hydrate  solu- 
tion contains  0.004  g.  of  XaHO,  the  58  aciditj^  means  that  it  would 
require  58  x  0.004  g.  XaHO  to  neutralize  the  amount  of  acid  pres- 
ent. Therefore  58  x  0.004  =  0.232  %  =  total  acidity,  or  2.32  per 
thousand  XaHO.  Should  this  result  be  desired  in  terms  of  hydro- 
chloric acid,  we  can  utilize  the  formula  XaHO  :  HCl  :  :  40  :  36.5, 
from  which  the  acidity  58  =  0.212%  =2.12  %  HCl. 

The  determination  of  the  total  acidity  is  the  most  im- 
portant feature  of  the  examination.  If  the  stomach  was 
washed  out  thoronghly  until  clear  fluid  is  returned,  before 
the  test  meal,  then  the  acid  present  after  the  test  meal  may 
be  considered  to  be,  for  the  greatest  part,  hydrochloric  acid, 
even  if  the  methyl-violet  reaction  is  negative.  The  bine  re- 
action of  the  methyl-violet  is  interfered  wdth,  as  well  as  are 


8S  DISEASES   OF   THE    DIGESTIVE    SYSTEM  chap. 

the  other  color  reactions,  should  there  be  a  large  quantity 
of  albuminoids  in  the  fluid  examined.  The  color  reaction 
should  be  controlled  by  the  biuret  test ;  should  this  be  posi- 
tively present,  then  it  is  proven  that  hydrochloric  acid  was 
effective  in  changing  albumin  to  peptone.  From  this  result 
the  conclusion  is  satisfactory  that  the  absence  of  the  hydro- 
chloric acid  color  reaction  is  no  proof  that  there  is  no  hydro- 
chloric acid  in  the  gastric  fluid.  On  the  other  hand,  the 
presence  of  the  color  test  indicates,  with  sufficient  certainty, 
that  hj'drochloric  acid  does  exist  in  the  fluid. 

Should  the  stomach  not  have  been  washed  out  before  the 
test  meal,  then  the  total  acidity  represents  the  combined 
hj'drochloric  and  other  organic  acids  (lactic,  acetic,  and 
butyric).  By  means  of  the  methyl-violet,  the  biuret,  and  the 
Uffelmann  tests,  the  valuable  conclusion  whether  much  or- 
ganic acid  is  present  is  reached.  Should  it  be  —  in  especially 
important  cases  —  desirable  to  determine  quantitatively  the 
amount  of  hydrochloric  and  lactic  acids,  complicated  chemi- 
cal methods  must  be  employed. 

The  gastric  fluid  obtained  two  hours  after  a  test  meal 
reacts  in  normal  cases.  Acid  and  litmus  gives  a  j)Ositive 
reaction  to  the  hydrochloric  acid  test,  as  well  as  to  the 
biuret  test,  but  no  reaction  to  the  lactic  acid  test. 

The  total  acidity  varies  between  50  and  (So  (c.c.  -^  normal 
sodium  hydrate  solution  to  100  c.c.  of  filtered  solution)  = 
0.18  to  0.24  %  of  hydrochloric  acid. 

The  hydrochloric  acid  reactions  are  absent  in  gastritis 
and  in  carcinoma  of  the  stomach ;  they  are  often  markedly 
increased  in  ulcer  of  the  stomach  and  in  nervous  dyspepsia. 

The  failure  of  the  hydrochloric  acid  reaction  is  by  no 
means  calculated  to  disprove  the  presence  of  carcinoma 
of  the  stomach ;  still  a  marked  presence  of  this  reaction 
would  contra-indicate,  in  most  cases,  the  existence  of  that 
disease. 

The  proof  of  the  presence  of  a  large  quantity  of  lactic 


IV  DISEASES    OF   THE    DIGESTIVE    SYSTEM  89 

acid  would  strongly  indicate  carcinoma.  The  test,  however, 
is  only  conclusive  providing  the  stomach  has  been  well 
washed  out,  and  the  test  meal  is  deficient  in  food  contain- 
ing lactic  acid  (Boasts  test  meal,  see  p.  86). 

Ill  addition  to  the  acids,  the  stomach  contains  the  digestive  fer- 
ments, pepsin,  which  peptonizes  the  albuminoids,  rennet  ferment, 
Avhich  coagulates  milk,  and  their  precursors,  pepsinogen  and  lab- 
zyniogen.  Tlie  examination  for  these  ferments  lias  as  yet  no 
essential  diagnostic  significance,  as  they  are  present  in  most  cases 
of  stomach  disease. 

The  consideration  of  the  artificially  obtained  gastric  fluid 
(the  question  of  the  relation  between  the  amount  thus 
obtained  and  the  amount  of  food)  justifies  the  conclusion 
as  to  how  much  food  the  stomach  has  passed  into  the  intes- 
tine (the  motor  activity  of  the  stomach).  From  this  not 
infrequently  a  judgment  as  to  the  improvement  or  non- 
improvement  of  a  case  may  be  formed.  According  to  Leube 
every  stomach  is  deemed  insufficient  from  which  remnants 
of  food  may  be  obtained  by  aspiration  seven  hours  after 
a  meaL 

A  better  method  of  determining  the  motor  activity  of  the  stom- 
ach is  by  means  of  the  salol  test.  Salol  passes  from  the  stomach  into 
the  intestine  unchanged,  and  is  split  up  only  by  the  alkaline  secre- 
tion of  the  intestine  into  salicylic  acid  and  phenol ;  the  reaction  of 
salicylic  acid  in  the  urine  (a  violet  color  on  the  addition  of  ferric 
chloride)  indicates  that  salol  has  passed  into  the  intestines.  Two 
(2)  grammes  of  salol  should  be  given  in  a  wafer  at  a  meal.  In  the 
normal  person,  the  reaction  for  salicylic  acid  will  be  obtained  in 
the  urine  in  f  to  1  hour  afterwards,  that  is,  urine  thus  obtained 
will  show  a  violet  color  to  ferric  chloride.  In  motor  weakness  of 
the  stomach  this  reaction  will  appear  from  2  to  5  hours  afterwards. 
In  addition  a  distinct  reaction  may  be  obtained  in  cases  of  good 
motor  function  at  the  utmost  up  to  24  hours  afterwards,  while  in 
motor  insufficiency  it  will  persist  for  2  days. 

It  is  desirable  to  determine  more  definitely  in  a  few  individually 
important  cases,  for  instance  in  stricture  of  the  pylorus,  the  motor 
activity  of  the  stomach.  For  this  purpose  100  c.c.  of  pure  olive  oil 
are  poured  into  the  stomach  which  has  been  previously  washed  out, 


90  DISEASES   OF   THE   DIGESTIVE   SYSTEM  chap. 

and  after  2  hours  an  aspiration  of  the  gastric  fluid  is  made  (oil 
test).  The  normal  stomach  will  pass  50  to  75c.c.  of  the  100  c.c.  of 
oil  that  had  been  given  into  the  intestine ;  in  very  many  diseased 
conditions  the  amount  of  oil  obtained  from  the  stomach  is  more  or 
less  diminished. 

Chief  Symptoms  of  the  Most  Important  Diseases  of 

THE  Stomach 

Acute  gastritis.  —  Severe  dyspeptic  symptoms  are  prominent. 
It  is  caused  chiefly  by  errors  in  diet.  Vomiting  is  an  accompani- 
ment, together  with  diminution  or  absence  of  hydrochloric  acid. 
The  region  of  the  stomach  is  tender.  Xot  infrequently  there  is 
headache  and  some  fever.  The  termination  is  mostly  favorable, 
still  a  transition  into  a  chronic  gastric  catarrh  is  possible. 

Ulcer  of  the  stomach  (ulcus  ventriculi).  —  Is  manifested  by  local- 
ized pain,  with  vomiting  after  the  ingestion  of  food,  the  vomited 
material  being  often  strongly  acid.  Vomiting  of  blood  also  occurs 
(hremafemesis).  The  condition  of  nutrition  of  the  body  is  some- 
what below  par.  The  acidity  is  most  always  increased,  still  when 
anaemia  is  present  it  may  be  diminished. 

Carcinoma  of  the  stomach.  —  There  is  a  palpable  tumor  of  the 
organ.  Vomiting  of  a  contents  of  a  coffee-ground  appearance 
occurs ;  the  patient  is  distinctly  cachectic.  The  reaction  to  the  test 
for  hydrochloric  acid  is  almost  always  absent,  but  lactic  acid  in  the 
stomach  contents  is  increased.  The  duration  of  the  disease  is 
between  2  and  3  years. 

The  dyspeptic  symptoms  which  appear  in  old  persons  unaccom- 
panied by  a  palpable  tumor  and  by  vomiting,  and  which  in  spite 
of  a  rational  system  of  treatment  persist  and  lead  to  excessive  ema- 
ciation, may  be  mistaken  for  carcinoma  of  long  standing. 

Dilatation  of  the  stomach.  —  At  more  or  less  long  intervals  vom- 
iting of  large  quantities  takes  place.  The  lower  border  of  the 
distended  stomach  lies  below  the  umbilicus.  The  bowels  are  con- 
stipated, the  amount  of  urine  is  small,  and  the  skin  is  dry. 
Emaciation  is  noticeable. 

The  diagnosis  should  at  the  same  time  embrace  the  causative 
factor  of  the  disease :  whether  the  disorder  is  due  to  stricture  of 
the  pylorus  or  to  atony  of  the  muscular  structure  of  the  stomach. 
The  cause  of  stricture  is  to  be  found  in,  either  a  cicatricial  forma- 
tion (due  to  an  ulcer  or  to  the  inflammation  resulting  from  caustic 
substances  taken  into  the  stomach)  or  in  a  carcinoma.     The  strict- 


IV  DISEASES   OF  THE   DIGESTIVE    SYSTEM  91 

ure  is  sometimes  produced  in  rare  instances  by  the  compression  of 
a  tumor,  by  twist  or  bend  of  the  duodenum  caused  by  peritoneal 
adhesions,  by  a  floating  kidney,  etc.  The  atonic  dilatation  is  the 
result  of  direct  distention,  due  to  excessive  drinking  and  gluttony, 
and  of  chronic  gastric  catarrh. 

Chronic  gastritis.  —  Palpation  and  percussion  of  the  stomach 
demonstrates,  outside  of  the  abnormal  sensitiveness  of  the  organ, 
no  foundation  for  the  severe  dyspeptic  symptoms.  If  proof  of  taking 
injurious  substances  into  the  organ  can  be  deduced,  the  diagnosis 
of  the  disease  is  probable.  The  stomach  contents  contain  much 
mucus,  and  the  acidity  is  diminished  (still  in  a  few  cases  it  is 
increased). 

Nervous  dyspepsia.  —  The  symptoms  which  may  be  objectively 
demonstrated  give  no  indication  of  the  severity  of  the  disorder. 
There  is  often  diffuse  pain  over  the  stomach,  mostly  independent 
of  the  ingestion  of  food  and  the  position  of  the  body,  and  often 
hydrochloric  hyperacidity.  AYhen  a  neurotic  condition  can  be 
demonstrated  and  neurasthenic  symptoms  are  present,  the  diag- 
nosis is  easy ;  it  may  also  be  made  if  the  causes  W'hich  lead  to 
gastritis  can  be  excluded. 

DiAGXOSIS    OF    THE    DISEASES    OF    THE    IXTESTIXES    AXD 
THE    PeEITO?s^EUM 

The  diseases  of  the  intestines  and  of  tlie  peritoneum  are 
recognized  outside  of  the  consideration  of  the  general  con- 
dition of  the  patient  by  an  examination  of  the  fences  and  of 
the  abdomen. 

The  normal  person  has  one  or  two  movements  of  the  bowels  in 
twenty-four  hours.  The  stool  is  formed  and  of  the  consistency  of 
thick  mush.  Thin  or  ßuid  stools  constitute  diarrJicea.  (See  p.  9.3.) 
The  color  and  amount  of  the  fseces  depend  upon  the  food.  When 
meat  has  been  the  chief  article  of  diet,  the  amount  is  small,  the 
color  is  brownish,  and  the  fjecal  mass  is  mm ;  when  chiefly  bread 
and  potatoes  are  eaten,  it  is  more  voluminous,  soft,  and  yellowish 
brown;  when  milk  is  exclusively  taken,  it  is  yellowish  white,  and 
tolerably  firm. 

The  ordinary  color  of  the  f?eces  is  caused  partly  by  the  reduced 
coloring  matter  of  the  bile  (hy drobilirubin ) .  The  reduction  is 
caused  bv  the  bacteria  in  the  intestines. 


92  DISEASES   OF  THE   DIGESTIVE   SYSTEM  chap. 

AhnonnaUy  colored  stools:  black  stools  are  the  result  of 
haemorrhage  (see  below),  or  are  occasioned  by  medicines, 
such  as  iron,  bismuth,  which  form  respectively  sulphide  of 
iron  and  sulphide  of  bismuth.  Green  stools  are  produced 
by  mercury,  especially  by  calomel,  which  forms  mercuric 
sulphide  at  the  same  time  as  it  does  biliverdin,  or  by  the 
passage  through  the  intestine  of  unchanged  bile,  which 
occurs  in  the  summer  diarrhoea  of  children.  Grayish-white 
stools  occur  in  fseces  free  from  bile,  and  when  the  faeces 
contain  much  fat. 

Fatty  stools  are  grayish- white,  mucilaginous,  and  smell 
badly ;  they  occur  as  the  result  of  the  occlusion  of  bile  from 
the  intestine  (icterus),  and  in  addition  chiefly  from  chronic 
peritonitis  and  intense  anaemia. 

Bloody  stools  appear  as  blackish-brown  faecal  masses  look- 
ing like  tar,  and  are  present  in  enteritis,  tumors  of  the  intes- 
tine, embolism  of  the  mesenteric  arteries,  in  typhoid  fever, 
and  in  purpura.  Haemorrhages  from  piles  give  rise  to  a 
bright-red  color  of  the  stool. 

Pundent  stools.  Should  the  stool  contain  only  pus,  the 
perforation  of  a  peritoneal  exudate  into  the  intestine  may 
be  diagnosed ;  when  only  mixed  in  small  quantities  in  the 
faecal  mass,  and  associated  with  fluid  and  at  times  bloody 
stools,  it  would  indicate  an  ulcer  of  the  large  intestine. 
Bloody  purulent  stools,  frequently  in  small  amounts  and 
accompanied  by  severe  tenesmus,  indicate  dysentery. 

Mucous  stools.  Pure  mucus  denotes  catarrh  of  the  rec- 
tum, as  does  the  encapsulation  of  the  scybalous  stool  with 
mucus. 

Small  particles  of  mucus  intimately  mixed  like  grains 
(often  like  sago-grains,  or  only  microscopically  demonstrable) 
in  the  formed  stool,  indicate  the  presence  of  a  catarrh  of 
the  small  intestine.  Sometimes  these  particles  are  colored 
with  bile.  Mucous  formation  in  the  shape  of  tubes  (mucous 
casts)  occurs  in  mucous  colic  (a  secretory  neurosis  of  the  large 


iv  DISEASES   OF  THE   DIGESTIVE   SYSTEM  93 

intestine).  Particles  of  the  tisHues  in  the  stool  indicate 
an  ulcerative  process. 

Microscopical  examination  may  reveal  nmscular  fibres,  fat  (in 
masses,  in  particles,  or  as  crystals),  crystals  of  triple-phosphates, 
Charcot-Leyden  crystals  (often  with  entozoa).  Leucocytes  are  only 
of  diagnostic  importance  when  very  numerous.  Mucous  particles 
may  also  be  seen.  In  chronic  catarrh  one  will  often  find  des- 
quamated epithelium  (homogeneous,  non-nucleated,  and  spindle 
forms) . 

Constipation  occurs  in  people  of  sedentary  habits,  and  is 
often  the  result  of  deficient  physical  exercise,  of  excessive 
eating  of  meat,  or  of  deficient  ingestion  of  fluids ;  it  occurs 
in  patients  who  are  compelled  to  lie  in  bed,  as  the  result  of 
the  unaccustomed  rest ;  frequently  it  is  jjresent  in  cases  of 
pregnancy  and  in  cases  of  hysteria ;  also  in  cases  of  dilata- 
tion of  the  stomach,  in  appendicitis,  in  cases  of  obstructive 
venous  circulation,  such  as  results  from  uncompensated 
heart  lesions,  etc.  Still  diarrhoea  also  occurs  in  these 
cases.  When  alternating  with  attacks  of  diarrhoea,  it  indi- 
cates chronic  intestinal  catarrh.  Long-continued  constipa- 
tion occurring  at  the  same  time  with  an  inability  to  pass  gas 
should  awaken  the  suspicion  of  an  intestinal  obstruction 
(ileus,  see  p.  95). 

DiARRHCEA 

Thin  copious  stools  are  produced 

1.  By  increased  peristalsis,  which  is  caused  by  (a)  nervous 
shocks,  such  as  fright,  fear ;  (h)  cold ;  (c)  irritating  substances 
which  appear  in  the  intestinal  tract,  especially  those  that  ferment 
and   decompose   (gastro-intestinal   catarrh,    summer    diarrhoeas) ; 

(d)  specific  bacterial  influences,  probably  likewise  producing 
irritating    chemical    changes    (colitis,    dysentery,    and    cholera) ; 

(e)  ulcerative  processes  in  the  mucous  membrane  (exfoliative 
ulceration  as  in  chronic  enteritis;  typhoid,  tubercular,  and  syphil- 
itic ulcerations)  ;  (/)  the  circulation  of  toxic  compounds  in  the 
blood,  as  in  urgemia  and  probably  in  carcinoma. 

2.  By  the  fact  that  owing  to  the  degeneration  of  the  epithelium 
of  the  intestine,  an  adequate  resorption  of  chyme  does  not  take 


94  DISEASES   OF  THE   DIGESTIVE   SYSTEM  chap. 

place.  The  series  of  causes  just  mentioned  may  also  lead  to  this 
deficient  absorption.  To  this  category  belong  especially  (a)  amy- 
loid degeneration  of  the  intestinal  mucous  membrane ;  (b)  the 
obstruction  in  the  portal  circulation  (cirrhosis  of  the  liver)  and  in 
the  general  venous  circulation  (non-compensated  cardiac  disease). 
The  obstructive  conditions  lead  again  to  catarrh,  and  belong  there- 
fore in  part  to  the  first  group. 

o.  By  the  transudation  of  watery  fluids  into  the  intestine;  all 
infectious  and  inflammatory  states  fall  under  this  group. 

Diarrhoea  of  sJwrt  duration,  mostly  without  significance 
yet  leading  quickly  under  certain  conditions  to  severe  symp- 
toms, occurs  in  cases  of  nervous  or  psychic  excitement,  in 
exposure,  in  acute  gastro-intestinal  catarrh,  and  is  also 
infectious,  especially  when  occurring  in  children.  It  occurs 
as  a  symptom  of  cholerine,  summer  diarrhoea,  and  cholera 
nostras. 

Diarrho'a  of  longer  duration,  chronic  diarrhoea,  occurs  in 
portal  obstruction ;  in  interference  with  the  general  return 
circulation  as  in  some  forms  of  heart  disease  ;  in  the  various 
intoxications,  e.g.  uraemia,  as  Avell  as  in  certain  sub-acute 
infectious  diseases,  such  as  typhoid  fever;  in  general  this 
kind  of  diarrhoea  justifies  the  diagnosis  of  a  grave  disorder 
of  the  intestine  (either  a  chronic  enteritis,  a  dysentery, 
a  tubercular  or  syphilitic  ulceration,  or  an  amyloid  degen- 
eration). Tuberculosis  of  the  intestine  is  only  to  be  diag- 
nosed with  any  degree  of  certainty  when  it  can  be  proven 
to  exist  in  other  organs  of  the  body,  and  amyloid  degen- 
eration only  when  one  of  its  etiological  factors,  such  as 
phthisis,  syphilis,  malaria,  abscess,  etc.,  is  present.  The 
situation  of  the  ulcerative  process  may  often  be  determined 
by  the  character  of  the  mucus  or  pus  mixed  with  the  fgecal 
discharges  (see  above).  The  following  diseases  have  char- 
acteristic stools :  typhoid  fever,  where  the  stool  has  a  ''  pea- 
soup  "  appearance ;  dysentery,  where  it  is  mucous  and  bloody ; 
and  cholera,  where  it  looks  like  "  rice-water." 


IV  DISEASES   OF  THE   DIGESTIVE   SYSTEM  95 


Abdomen 

Normal  relations.  The  abdomen  of  the  healthy  person  is  mod- 
erately arched,  moves  up  and  down  during  respiration,  is  usually 
soft,  easily  depressed,  and  nowhere  painful  on  palpation ;  offers 
no  resistance  anywhere  to  pressure  and  is  tympanitic  on  percussion 
excepting  when  the  colon  contains  large  fsecal  masses,  when  the 
percussion  note  may  be  dull. 

Retraction  of  the  abdomen.  The  abdomen  is  scapJioid  in  shape 
and  retracted  in  spasm  of  the  intestine  such  as  occurs  in  colic  and 
in  meningitis,  or  when  it  is  entirely  empty  as  in  inanition,  in  dilata- 
tion of  the  stomach,  and  in  stricture  of  the  oesophagus. 

Distention  of  the  Abdomen 

The  abdomen  may  be  highly  arched,  and  sometimes  tense  as  a 
drum.     These  conditions  are  caused  by 

I.  An  accumulation  of  gas  in  the  intestines  (meteorism,  tym- 
panites) ;  determined  by  the  general  tympanitic  resonance  on  per- 
cussion, the  absence  of  fluctuation.  Moderate  tympanites  occurs 
in  typhoid  fever,  in  chronic  intestinal  catarrh,  and  in  obstruction 
in  the  portal  circulation. 

A  high  degree  of  tympanites  occurs  with  (1)  intestinal  obstruction 
(ileus}.  The  diagnosis  of  ileus  is  rendered  certain  when,  in  addi- 
tion to  extensive  tympanites,  there  is  the  facies  of  collapse,  small 
frequent  pulse,  and /cecal  vomiting.  After  the  diagnosis  of  ileus  is 
made,  the  following  data  must  be  determined  :  1.  The  location  of 
the  obstruction ;  is  it  situated  in  the  small  or  large  intestine  ? 
2.  The  nature  of  the  obstruction,  which  may  be  an  invagination, 
a  twist  (volvulus),  a  strangulated  hernia,  a  constriction  due  to  a 
peritoneal  band,  a  peritoneal  abscess,  a  cicatrix  of  an  old  intestinal 
ulceration,  a  malignant  tumor,  a  foreign  body  such  as  a  gall-stone. 

The  hernial  canals  and  the  rectum  should  always  he  examined 
ivithout  fail.  Obstruction  of  the  small  intestine  is  accompanied 
by  active  visible  peristaltic  motion  in  the  intestines,  by  a  large 
amount  of  indican  in  the  urine  (Chap.  YIII.),  and  by  violent  general 
symptoms ;  in  obstruction  in  the  large  intestine,  a  great  amount  of 
distention  of  the  portion  of  the  colon  above  the  constriction  is 
observed,  the  urine  contains  but  little  indican,  and  the  general 
symptoms  develop  more  slowly.  The  diagnosis  of  the  nature  of  the 
obstruction  is  made  in  many  cases  from  the  history  of  the  case  and 
by  manual  examination,  but  can  not  often  be  absolutely  settled. 


96  DISEASES   OF  THE   DIGESTIVE   SYSTEM         chap. 

A  high  degree  of  tympanites  occurs  with  (2)  acute  general 
peritonitis,  where  every  movement  of  the  patient  is  attended 
by  pain,  as  is  every  touch  on  the  abdomen ;  in  addition  there 
are  present,  vomiting  of  bile,  a  small  frequent  pulse,  and 
the  fades  hippocratica. 

Even  ill  localized  peritonitis  an  ii'ritation  of  the  entire  perito- 
neum may  result,  so  that  the  symptoms  of  a  general  peritonitis 
may  be  closely  imitated.  The  diagnosis  is  determined  by  the 
proof  of  the  presence  of  an  exudate. 

II.  B}'  a  collection  of  free  fluid  in  the  peritoneal  cavity 
(ascites) .  In  these  cases  the  abdomen,  when  the  patient  is  \jmg 
down,  is  distended  at  its  sides  and  flattened  in  the  middle ;  above 
there  is  tympanitic  percussion,  while  dulness  is  elicited  in  its 
dependent  parts.  Dulness  on  percussion  is  bounded  above  by  a 
horizontal  line  and  is  changed  by  a  change  in  the  position  of  the 
patient.  On  taj^ping  the  side  of  the  abdomen  with  the  fingers, 
fiuctuation  is  often  elicited. 

If  the  patient  is  placed  on  his  side,  a  tympanitic  percussion  note 
is  obtained  over  the  side  which  is  uppermost ;  should  the  position  be 
changed  to  the  recumbent  one,  dulness  on  percussion  will  be  found 
on  the  side  which  had  just  shown  a  tympanitic  note. 

Should  ascites  have  been  diagnosed,  the  following  possibihties 
should  be  regarded  :  — 

1.  Ascites,  together  with  general  oedema,  occurs  in  cardiac  and 
renal  diseases,  but  the  ascites  is  only  a  secondary  development 
to  the  original  oedema,  and  is  of  itself  not  of  essential  impor- 
tance. 

Still,  in  consequence  of  a  long-continued  ascites,  oedema  of  the 
legs  may  follow  as  a  result  of  the  pressure  of  the  fluid  on  the  veins 
and  of  the  anaemia. 

2.  Ascites  may  be  unaccompanied  by  general  oedema,  or 
only  by  a  secondary  oedema  of  the  legs.  In  this  case  there 
is  present  either :  — 

(a)  Obstruction  to  the  j^ortal  circulation  by  reason  of 
hepatic  disease  or  occlusion  of  the  portal  vein;  under  these 
conditions  the  ascitic  fluid  contains  very  little  albumin,  and 
varies  in  specific  gravity  from  1006  to  lOlo. 

(h)  Chronic  peritonitis.     In  this  case  the  ascitic  fluid  con- 


IV  DISEASES   OF  THE    DIGESTIVE    SYSTEM  97 

tains  a  larger  percentage  of  albumin,  and  its  specific  gravity 
is  1018. 

The  specific  gravity  is  measured  by  a  urinometer,  the  fluid  to 
be  examined  being  at  the  temperature  of  the  room.  \Vhen  taken 
at  the  temperature  of  the  body,  it  is  lower  than  under  the  former 
conditions  ;  it  is  1°  of  the  urinometer  lower  for  every  3°  C.  elevation 
above  the  temperature  of  the  room.  From  the  specific  gravity  the 
amount  of  albumin  may  be  proximately  determined,  in  this  manner, 
according  to  Reiiss's  formula,  Ä  =  |(*S  —  1000)  —  2.8,  where  Ä  repre- 
sents the  amount  of  albumin  in  per  cent.,  S,  the  specific  gravity. 

To  return  to  (a),  which  we  might  call  congestive  ascites, 
it  occurs  chiefly  in  diseases  of  the  liver,  and  especially  in 
hepatic  cirrJiosis.  Accompanying  the  ascites  is  a  distention 
of  the  veins  of  the  abdomen,  especially  those  about  the 
umbilicus  (forming  the  ccqnit  meclusce) ;  in  addition  the 
spleen  is  enlarged,  and  the  stomach  and  intestines  are 
the  seat  of  a  catarrhal  inflammation.  From  the  history 
will  be  elicited  that  the  patient  has  indulged  excessively 
in  alcohol.  In  rare  instances  syphilis  produces  a  peculiar 
variety  of  hepatic  cirrhosis  {hepar  lobatum),  Avhich  proceeds 
without  ascites,  and  always  runs  a  chronic  course. 

The  other  diseases  of  the  liver,  especially  carcinoma  and  syphi- 
lis, give  rise  only  seldom  to  ascites,  and  are  diagnosed  by  the 
absence  of  the  characteristic  signs  of  cirrhosis,  by  palpation,  and 
by  the  history. 

Occlusion  of  the  portal  vein  occurs  very  rarely,  and  is  then  pro- 
duced by  tumors  of  the  stomach,  of  the  pancreas,  etc.,  or  by  a 
thrombosis  of  the  vein. 

(b) .  Chronic  peritonitis  is  produced  by  carcinomatosis  or 
by  tuberculosis  of  the  peritoneum,  is  accompanied  by  gen- 
eral cachexia,  and  the  diagnosis  is  made  positive  when 
either  carcinoma  or  tuberculosis  is  discovered  in  one  or 
more  of  the  other  organs. 

In  chronic  peritonitis  the  ascites  may  be  encapsulated  by  peri- 
toneal adhesions.     In  such  a  case  the  change  of  the  position  of  the 
patient  may  not  give  rise  to  change  in  the  percussion  note.     Fric- 
u 


98  DISEASES   OF  THE   DIGESTIVE   SYSTEM         chap. 

lion  sormds  may  be  heard  and  friction  be  felt.  Occasionally  an 
infiltration  of  the  abdominal  wall  aronnd  the  umbilicus  is  found 
(periomphalitis) . 

III.  By  tumors,  in  which  case  the  abdominal  distention 
is  often  asymmetrical,  being  most  prominent,  not  infre- 
quently, at  the  site  of  the  organ  affected.  Over  the  dis- 
tended area  dulness  on  percussion  is  present.  -Tympanites 
may  occur  at  the  same  time.  A  diagnosis  of  tumor  can 
only  be  certain  when  a  tumor  can  he  felt. 

We  should  be  on  our  guard  not  to  confound  tumor  with  an  ac- 
cumulation of  fseces  in  the  intestine.  In  the  latter  case  the  mass 
is  doughy  in  consistency,  easily  indented,  and  disappears  after  a 
free  catharsis. 

Tumors  may  arise  in  the  liver,  the  spleen,  the  kidneys,  the 
intestines,  the  stomach,  the  omentum,  and  only  seldom  in  the 
A^ertebra  and  the  pelvic  bones,  in  the  aorta  (pulsating  aneurysm), 
and  in  the  female  genital  organs. 

A  tumor  in  the  ileoccecal  region  of  the  size  of  an  Qgg,  an 
orange,  or  even  up  to  a  saucer,  if  tender  and  combined  with 
fever,  vomiting,  and  tympanites,  denotes  the  presence  of  an 
appendicitis  or  perityphlitic  exudation. 

Tumors  of  the  ovary  and  tlie  pregnant  uterus  will  show  dul- 
ness on  percussion  over  the  lower  half  of  the  abdomen ;  the  upper 
boundary  of  dulness  is  convex  upwards,  and  in  the  lateral  parts  of 
the  abdomen  in  the  recumbent  position  it  is  tympanitic ;  there  is 
no  change  in  percussion  note. 

To  determine  from  which  organ  the  tumor  arises  is  often 
extremely  difficult.  To  assist  in  the  diagnosis,  various  aids 
are  called  into  requisition,  such  as  ballooning  the  stomach 
or  filling  it  with  water,  or  by  doing  the  same  to  the  colon 
by  means  of  a  rectal  tube. 

IV.  By  the  escape  of  gas  into  the  peritoneal  cavity.  Gas 
in  the  abdominal  cavity  will  always  rise  to  the  top,  so  that 
when  the  patient  lies  on  the  left  side,  the  area  of  liver  dul- 
ness will  disappear,  and  when  on  the  right  side,  no  splenic 
dulness  can  be  elicited.     Gas  within  the  peritoneal  cavity 


IV  DISEASES   OF  THE   DIGESTIVE   SYSTEM  99 

is  the  pathognomonic  sign  of  a  2)^'i\forcitio7i  x>eritonitis,  which 
is  almost  invariably  fatal. 

Perforation  of  the  stomach  may  be  produced  by  a  long-standing 
ulcer  of  the  stomach,  especially  after  an  intense  bodily  strain,  or 
after  a  full  meal;  perforation  of  the  intestine  may  result  from 
an  ulcerative  process  in  that  viscus,  especially  occurring  in  the 
remission  stage  of  typhoid  fever,  and  after  there  has  been  a  haemor- 
rhage from  the  bowel.  Another  frequent  cause  of  perforation 
peritonitis  is  the  perforation  of  the  vermiform  appendix  by  a 
faecal  concretion. 

The  disappearance  of  liver  dulness  has  a  fatal  significance  only 
when  at  the  same  time  a  change  in  position  of  the  patient  produces  a 
change  of  percussion  note;  changing  the  patient's  position,  how- 
ever, occasions  intense  pain,  and  should  be  done  only  in  cases  of 
urgent  necessity.  Perforation  peritonitis  is  also  made  apparent 
by  the  signs  of  great  collapse,  as  well  as  by  the  local  signs. 

The  liver  dulness  is  absent  frequently  in  ordinary  tympanites  of 
moderate  amount,  such  as  occurs  in  constipation ;  in  addition,  it 
may  be  absent  or  much  diminished  in  diseases  of  the  liver,  which 
lead  to  atrophy,  such  as  acute  yellow  atrophy  and  cirrhosis.  In 
acute  atrophy  of  the  liver  a  progressive  diminution  in  liver  dul- 
ness may  be  seen  taking  place  from  day  to  day.  It  is  diminished 
in  cases  of  extensive  pulmonary  emphysema,  where  the  distended 
lungs  overlap  the  liver  area. 

Chief  Symptoms  of  the  Most  Important  Diseases  of 
THE  Intestines  and  Abdomen 

Acute  intestinctl  catarrh:  suddenly  developing  diarrhoea, 
w^itli  colic  and  tenesmns.  In  severe  cases  the  final  evacua- 
tions contain  much,  watery  mncns.  It  is  often  preceded 
by  vomiting,  and  is  sometimes  accompanied  by  fever. 
There  is  almost  always  more  or  less  depression.  Chronic 
intestinal  catarrh  is  characterized  by  a  diarrhoea,  which  lasts 
for  months,  consisting  of  mncns,  pus  and  bloody  stools, 
alternating  wdth  constipation,  slow^  emaciation.  Specific 
causes,  such  as  tuberculosis,  syphilis,  dysentery,  and  car- 
cinoma, which  may  likewise  be  the  cause  of  a  chronic 
catarrh,  should  be  excluded  in  making  a  diagnosis. 


100  DISEASES   OF   THE   DIGESTIVE    SYSTEM  chap. 

Mucous  colic  (formerly  known  as  enteritis  memhranaceci)  is  a  rare 
form  of  intestinal  affection,  occurring  in  neuropathic  individuals, 
and  characterized  by  a  diarrhoea  accompanied  by  attacks  of  colic, 
the  stools  containing  tape-like,  cylindrical,  pseudomembranous 
casts  of   coagulated  mucus. 

Carcinoma  of  the  intestine :  cachexia,  and  a  palpable  tumor 
in  the  abdomen,  which  is  often  very  movable.  The  intestine 
may  be  moved  with  the  tumor.  It  is  frequently  associated 
with  signs  of  intestinal  obstruction  (see  p.  95)  and  with 
haemorrhages  from  the  bowels.  Tumors  of  the  rectum  can 
usually  be  felt  from  the  anus. 

Ileus.     (See  p.  95.) 

Acute  general  peritonitis.  There  is  extensive  tympanites, 
vomiting  of  bile  (spinach-green  vomiting),  at  times  singul- 
tus. The  abdomen  is  intensely  tender,  and  when  due  to  a 
perforation  the  liver  dulness  gives  place  to  tympanitic  per- 
cussion, owing  to  the  contained  gas  rising  to  that  region. 
The  facies  of  collapse  are  well  marked,  the  pulse  is  frequent 
and  small,  and  respiration  is  shallow  and  rapid. 

Localized  peritonitis.  The  general  symptoms  approxi- 
mate more  or  less  those  of  general  peritonitis,  though  as  a 
rule  they  are  much  less  intense.  By  palpation  a  localized 
exudation  can  be  felt.  The  rectum  should  be  examined  by 
the  finger  for  this  purpose. 

Perityplilitis,  ajipendicitis.  A  painful  infiltration  or  ex- 
udation in  the  ileocsecal  region  may  be  felt.  On  percussion 
it  is  dull.  There  is  vomiting,  tympanites,  constipation,  and 
fever.  The  pulse  is  good,  as  a  rule.  It  ends  frequently  in 
spontaneous  absorption,  though  rupture  of  the  abscess  occurs ; 
operation  is  not  infrequently  necessary. 

Chronic  peritonitis.     (See  p.  97.) 

Diagnosis  of  Diseases  of  the  Liver 

The  important  data  to  be  obtained  in  simple  jaundice  (icterus) 
are:  mistakes  in  diet,  previous  gastric  catarrh,  fright,  anger;  when 
severer  symptoms  are  present  the  following :  a  previous  attack  of 


IV  '  DISEASES   OF   THE   DIGESTIVE   SYSTEM  101 

jaundice,  especially  of  biliary  colic  (gall-stone)  ;  a  history  of  alco- 
holism (cirrhosis)  ;  of  companionship  with  dogs  (echinococcus)  ; 
of  syphilis.  One  should  determine  also  whether  the  etiological 
factors  of  amyloid  degeneration  are  present  and  whether  there  has 
been  any  history  of  poisoning,  for  instance,  with  phosphorus. 

Diseases  of  the  liver  are  recognized  in  many  cases  by  the 
presence  of  icterus,  which  is  first  observed  in  the  conjunctiva 
and  finally  over  the  skin  of  the  entire  body.  The  urine  is 
of  the  color  of  dark  beer,  shows  Gmelin's  reaction  (see 
Chap.  VIII.) ;  the  faeces  are  grayish-white,  like  day.  The 
following  types  are  recognized :  — 

1.  Icterus  simplex  (catarrhal  jaundice),  which,  is  associated 
with  mild  symptoms,  headache,  fatigue,  malaise,  itching 
of  the  skin,  and  a  slow  pulse.  It  arises  as  the  result  of 
the  occlusion  of  the  ductus  choledochus  by  a  catarrhal 
inflammation  of  its  mucous  membrane.  It  lasts  but  a  few 
weeks.  The  prognosis  under  proper  treatment  is  favor- 
able. 

2.  Icterus  gravis  occurs  with  severe  symptoms  of  disease, 
with  emaciation,  frequently  with  fever,  mental  confusion, 
delirium,  and  severe  pains  in  the  region  of  the  liver.  It 
may  be  produced  by  passage  of  a  gall-stone  or  impacted 
gall-stone,  by  liver  abscess,  by  echinococcus  of  the  liver,  by 
carcinoma  of  that  organ,  and  by  acute  yellow  atrophy. 

Concerning  icterus  with  polycholia  and  without  polycholia,  see 
p.  8.  The  clinical  consideration  of  cases  of  severe  jaundice  may 
present  many  prominent  symptom-combinations  which  serve  to 
make  the  diagnosis  easy ;  thus  icterus  comhined  with  cachexia  indi- 
cates hepatic  carcinoma;  when  combined  ivith  ascites  it  indicates 
cirrhosis;  icterus  occurring  with  attacks  of  colic  indicates  biliary 
calculi ;  when  associated  with  chilly  sensations,  abscess  of  the  liver  is 
probably  present.  Of  course  these  symptom-combinations  have 
only  a  limited  diagnostic  value ;  they  should  always  be  corrobor- 
ated by  the  other  signs  of  the  individual  diseases  elicited  only  by 
a  careful  examination.  Thus,  the  picture  of  a  jaundice  due  to 
gall-stone  may  be  simulated  by  a  carcinoma  of  the  duodenum  and 
that  of  cirrhosis  of  the  liver  by  a  chronic  peritonitis,  etc. 


102  DISEASES   OF  THE   DIGESTIVE   SYSTEM  chap. 

There  are  some  diseases  of  the  liver  in  which  jaundice 
appears  only  late  in  the  course  of  the  disease  or  7iot  at  all. 
They  are  amyloid  liver,  fatty  liver,  congestive  liver  (due  to 
impeded  venous  circulation),  carcinoma  of  the  liver,  syphil- 
itic liver,  atrophic  cirrhosis,  and  echinococcus.  The  attention 
of  the  clinician  is  drawn  to  the  liver  chiefly  by  the  patient's 
symptoms  of  pressure  and  pain  in  the  hepatic  region,  some- 
times by  the  ascites,  and  often  only  after  a  casual  physical 
examination  of  the  organ. 

A  differential  diagnosis  is  made  from  the  history  of  the 
case  and  the  general  condition  of  the  patient,  and  by 
the  physical  signs  obtained  by  percussion  and  xyalpation  of 
the  organ. 

The  liver  (compare  Fig.  24,  p.  83)  lies  in  the  right  hypochon- 
drium  and  its  upper  border  in  the  normal  state  reaches  the  inferior 
border  of  the  7th  rib  in  the  axillary  line;  in  the  mamillary 
line  it  reaches  the  inferior  border  of  the  6th  or  the  superior  bor- 
der of  the  7th  rib ;  its  upper  border  lies  behind  the  6th  rib  at  the 
right  sternal  line.  Its  inferior  bonier  in  the  axillary  line  lies 
between  the  10th  and  11th  ribs,  extends  across  the  costal  arch  in  the 
mamillary  line,  and  lies  midway  in  the  linea  alba  between  the 
xiphoid  process  and  the  umbilicus;  it  then  curves  upwards  and 
reaches  the  diaphragm  at  a  spot  between  the  parasternal  and 
mamillary  lines.     On  deep  inspiration  the  liver  descends  a  trifle. 

Percussion  of  the  liver  will  show  relative  dulness  in  the  mamil- 
lary line  from  the  4th  rib  downwards,  which  changes  to  absolute 
dulness  (flatness)  at  the  lower  border  of  the  6th  rib.  The  latter 
ends  in  the  mamillary  line  at  the  free  border  of  the  ribs,  when  the 
percussion  note  becomes  tympanitic.  Pcdpation  gives  no  results 
in  the  normal  condition  of  the  organ  in  the  mamillary  line.  But  in 
hypertrophij  of  the  liver  the  edge  of  the  liver  may  be  felt  below  the 
free  border  of  the  ribs  and  percussion  will  show  dulness  also  below 
the  free  border. 

Jjiver  dulness  is  increased  always  in  hypertrophic  cirrhosis, 
in  amyloid  degeneration  of  the  liver,  in  chronic  congestion 
of  the  liver,  often  fatty  degeneration  of  the  liver,  in  hepatic 
echinococcus,  carcinoma,  and  abscess. 


IV  DISEASES   OF   THE   DIGESTIVE    SYSTEM  103 

Liver  dulness  may  extend  beyond  the  free  border  of  the  ribs 
even  when  the  liver  is  not  increased  in  size,  providing  the  dia- 
phragm is  shoved  doiünivards,  as  occurs  in  puhnonary  emphysema, 
in  pneumothorax,  and  in  pleuritic  effusions  on  the  right  side. 

Liver  dulness  is  diminished  in  area  in  acnte  yellow  atrophy 
(here  the  diminution  goes  on  from  day  to  day,  and  without  an 
increase  of  tympanites),  in  atrophic  cirrhosis  (diminution 
proceeds  extremely  slow),  often  in  tympanites  when  the 
transverse  colon  lies  between  the  liver  and  the  abdominal 
parietes ;  should  extensive  tympanites  coexist  with  grave  gen- 
eral symptoms,  and  in  addition  should  it  be  possible  to  elicit 
by  a  change  of  the  position  of  the  patient  to  the  right  side  a 
liver  dulness  which  was  absent  when  the  patient  was  on  the 
left  side,  the  diagnosis  of  air  or  gas  in  the  peritoneal  cavity 
should  be  made  (perforation  peritonitis,  see  pp.  98,  99).- 

The  border  of  the  liver  is  felt  to  be  smooth  in  chronic 
congestion,  in  amyloid  degeneration,  and  in  hypertrophic  cir- 
rhosis. The  border  and  the  upper  surface  are  rough  (uneven 
and  nodular)  in  atrophic  cirrhosis,  in  syphilitic  hepatic  dis- 
ease, in  carcinoma,  and  sometimes  in  hepatic  abscess. 

A  special  form  of  liver  tumor  is  the  corset  or  tight-lace  liver 
(constricted  liver),  where  a  portion  of  the  right  lobe  lies  below 
the  free  border  of  the  ribs  as  an  isolated  tumor  extending  from 
4  to  6  cm.  into  the  abdominal  cavity.  Abnormal  mobility  of  the 
liver  is  known  as  floating  liver  (it  occurs  in  women  with  pendulous 
abdomens) . 

Chief  Symptoms  of  the  Most  Importaxt  Diseases  of 

THE  LrnER 

Catarrh  of  the  bile-ducts  (catarrhal  jaundice)  is  characterized  by 
icterus,  accompanied  by  mild  symptoms  (see  pp.  8  and  101);  the 
liver  is  often  enlarged,  is  but  little  tender,  and  the  gall-bladder  is 
often  palpable.  A  favorable  termination  occurs  in  from  3  to  5 
weeks. 

In  a  few  cases  it  progresses  to  chronic  jaundice  by  reason  of  the 
agglutination  of  the  mucous  walls  of  the  ductus  choledochus  and 


104  DISEASES    OF   THE   DIGESTIVE    SYSTEM  chap. 

the  occlusion  of  its  canal  (cholangitis  chronica  fibrosa).  As  a 
result  gradual  slow  emaciation  occurs  and  after  a  few  years,  death, 
preceded  by  coma  and  convulsions,  ensues. 

Abscess  of  the  liver  gives  the  symptoms  of  jaundice,  combined 
with  erratic  chills,  emaciation,  severe  pains  in  the  region  of  the 
liver  and  in  the  right  shoulder.  In  solitary  abscess  a  protrusion  of 
the  liver  surface  upwards  or  downwards  is  sometimes  observed. 
In  multiple  abscesses  the  liver  is  not  infrequently  enlarged 
throughout. 

Biliary  colic  (gall-stone  colic)  is  accompanied  by  very  severe 
attacks  of  pain  in  the  hepatic  region  of  varying  duration  and 
occasionally  by  jaundice ;  vomiting  and  fever  are  not  infrequent. 
The  diagnosis  is  rendered  positive  by  the  finding  of  gall-stones  in 
the  faeces. 

Analysis  of  gall-stones.  Gall-stones  are  composed  of  con- 
cretions either  of  hiliruhin  or  of  Cholesterin.  Cholesterin  is 
tested  for  as  follows  :  a  portion  of  the  calculus  is  dissolved 
in  hot  alcohol  and  the  solution  is  then  filtered;  from  the 
filtered  solution,  when  cool,  Cholesterin  forms  in  rhombic 
crystals.  To  continue  the  test,  the  crystals  are  dissolved 
in  chloroform  and  concentrated  sulphuric  acid  is  added  to 
the  solution,  when  a  beautiful  deep-red  color  appears,  which 
gradually  changes  to  blue  and  finally  green.  Bilirubin  is 
isolated  by  extracting  from  the  remaining  filtrate  with  warm 
chloroform,  the  filtrate  having  previously  been  rendered 
slightly  acid  with  hydrochloric  acid,  when  it  is  observed  in 
the  chloroform  solution  on  the  addition  of  fuming  nitric 
acid  {Gmelin''s  test). 

Carcinoma  of  the  liver  give  rise  to  cachexia,  combined  with 
icterus ;  palpable,  nodular  tumor  in  the  liver  region  ;  usually 
decided  enlargement  of  the  liver  without  any  enlargement 
of  the  spleen. 

Acute  yellow  atrophy  of  the  liver  is  diagnosed  when  a 
suddenly  developing  jaundice  occurs  associated  with  severe 
cerebral  symptoms  snch  as  confusion,  delirium,  and  coma; 
with  a  rapid  diminution  of  liver  dulness.  Tyrosin  and 
leucin  are  found  in  the  urine,  the  excretion  of  urea  is  very 


IV  DISEASES   OF   THE   DIGESTIVE   SYSTEM  105 

much   diminished,   the    excretion   of   ammonia  very  much 
increased.     It  pursues  a  rapidly  lethal  course. 

Acute  yellow  atrophy  may  appear  after  an  initial  stage  of 
catarrhal  jaundice  lasting  from  8  to  14  days. 

Hypertrophic  cirrhosis  of  the  liver  is  characterized  by  the 
presence  of  jaundice,  combined  with  a  decidedly  uniform 
enlargement  of  that  viscus ;  alcohol  and  syphilis  are  the 
etiological  factors.  It  is  associated  with  a  visible  enlarge- 
ment of  the  veins  of  the  abdominal  walls,  with  a  hyper- 
trophy of  the  spleen,  and  with  gastro-intestinal  catarrh; 
ordinarily  it  is  unaccompanied  by  ascites. 

Atrophic  cirrhosis  of  the  liver  is  diagnosed  by  the  presence 
of  ascites,  the  ascitic  fluid  having  a  low  specific  gravity; 
by  the  distention  of  the  abdominal  veins  and  an  apprecia- 
ble splenic  enlargement.  There  is  a  slowly  developing 
cachexia  and  sometimes  jaundice.  Symptoms  of  gastro- 
intestinal catarrh.  The  history  will  show  excessive  drink- 
ing of  alcoholic  beverages,  more  seldom  syphilis  or  malaria 
or  chronic  peritonitis  or  cardiac  disease. 

Echinococcus  of  the  liver  is  only  to  be  diagnosed  when  by 
the  growth  of  the  cyst  the  liver  becomes  enlarged.  In 
well-developed  cases  fluctuation  and  hydatid  fremitus  over 
the  tense  elastic  tumor  may  be  elicited.  Aspiration  of  the 
tumor  mass  yields  a  fluid  in  which  portions  of  the  echino- 
coccus  membranous  wall  and  the  booklets  of  the  parasite 
may  be  found  on  microscopical  examination.  The  fluid 
does  not  become  turbid,  or  at  best  but  very  little,  on  heating 
(see  Chap.  XII.) 

Amyloid  degeneration  of  the  liver.  —  There  is  a  uniform 
firm  enlargement  of  the  organ  and  a  cachexia.  Proof  of 
the  etiological  factors,  such  as  phthisis,  syphilis,  suppuration, 
etc.,  will  assist  in  the  diagnosis.  The  spleen  is  enlarged  and 
albuminuria  and  diarrhoea  are  present. 

Chronic  congestion  of  the  liver  also  presents  a  uniformly 
enlarged   liver.      Dyspnoea  and  cyanosis   are  features  and 


106  DISEASES   OF  THE   DIGESTIVE    SYSTEM     chap,  iv 

point  to  the  primary  cause  of  the  disease ;  namely,  to  cardiac 
or  pulmonary  affections. 

The  Spleen 

Enlargement  of  the  spleen  is  an  extremely  important  sign, 
upon  which  dej^ends  the  diagnosis  of  many  diseases. 

The  spleen  is  situated  in  the  left  hypochondriiim.  Under  nor- 
mal conditions  splenic  dulness  extends  from  the  9th  to  the 
11th  rib,  and  from  the  linea  costo-articnlaris  (a  line  drawn  from 
the  left  sterno-clavicular  articulation  to  the  apex  of  the  11th  rib) 
to  the  vertebral  column.  Should  the  spleen  enlarge,  its  area  of 
dulness  will  be  increased  until  it  finally  extends  beyond  the  left 
costal  arch.  AVhen  the  organ  is  decidedly  enlarged,  its  edge  may  he 
felt  as  a  sharp  border,  especially  on  deep  inspiration.  Palpation  of 
the  viscus  is  often  painful. 

A  positive  proof  of  enlargement  of  the  spleen  is  only  pos- 
sible when  the  organ  can  be  felt  by  2Kdpation;  it  is  often 
possible  to  demonstrate  an  enlargement  by  percussion, 
though  the  results  of  percussion  are  frequently  deceptive 
on  account  of  the  variable  amount  of  faeces  in  the  colon. 

The  determination  of  splenic  enlargement  is  indispensable 
in  making  a  diagnosis  of  typhoid  fever,  of  malarial  intermit- 
tent, and  of  splenic  leucaemia;  it  is  desirable  to  demonstrate 
it  to  reach  a  diagnosis  of  amyloid  degeneration,  of  cirrliosis 
of  the  liver,  and  of  haemorrhagic  infarction  of  the  spleen. 

It  may  be  enlarged  in  all  infectious  diseases ;  in  addition 
to  typhoid,  in  pyaemia,  pneumonia,  etc.  Should  it  be  so 
found  with  pneumonia,  it  will  remain  demonstrable  until 
resolution  is  completed. 

The  spleen  may  be  disj^laced  downwards  in  left-sided  pleu- 
ral effusions,  in  pneumothorax,  and  in  pulmonary  emphy- 
sema. It  is  displaced  upwards  in  tympanites,  in  ascites,  and 
by  tumors  of  the  abdominal  cavity.  Percussion  dulness  dis- 
appears in  perforation  peritonitis  when  the  patient  lies  on 
the  right  side,  and  in  general  is  absent  over  the  splenic 
region  in  cases  of  floating  spleen. 


CHAPTER   V 

DIAGNOSIS    OF   THE   DISEASES    OF   THE   UPPER   AIR- 
PASSAGES    (NOSE,    THROAT,    LARYNX) 

The  diseases  of  the  nose,  to  wliicli  attention  is  directed  by 
the  discharge,  pain,  and,  above  all,  the  occlusion  of  the  nose, 
may  be  recognized  by  inspection  with  the  nasal  speculum 
and  palpation  with  the  nasal  probe.  The  symptomatology 
of  all  the  diseases  of  the  nose  would  overstep  the  bounds 
of  this  work,  and  only  those  symptoms  will  be  considered 
which  are  of  importance  in  internal  medicine. 

Headache,  especially  frontal,  is  a  symptom  of  many  diseases 
of  the  nose.  It  may  be  present  in  a  mild  degree  in  an  ordi- 
nary cold,  usually  to  be  referred,  however,  to  disease  of  the 
frontal  cavity.  Purulent  processes  in  this  cavity  (empyema 
of  the  frontal  sinus)  may  give  rise  to  meningitis ;  next  to 
inflammations  of  the  middle  ear,  the  nose  is  probably  the 
most  frequent  source  of  meningeal  infection. 

Neuralgia  of  the  branches  of  the  trigeminus  is  not  rarely 
seen  in  disease  of  the  nasal  accessory  chambers,  and  has  been 
observed  especially  in  connection  with  disease  of  the  antrum 
of  Highmore. 

Epistaxis  demands  an  examination  of  the  nose ;  but  the 
constitutional  causes  must  not  be  lost  sight  of  (chlorosis, 
leucaemia,  anaemia,  cirrhosis  of  the  liver,  contracted  kidney, 
etc.). 

A  foul  smell  in  the  nose  is  the  sign  of  ozcena.  The  nasal 
cavity  is  broadened  (atrophy  of  the  turbinated  bones),  the 
mucous  membrane  thin,  pale,  covered  with  numerous  crusts. 

107 


108        DISEASES   OF  THE   UPPER   AIR-PASSAGES        chap. 

The  peculiar  bad  odor  clings  to  the  dried  secretion.  The 
secretion  may  be  expelled  through  the  nasopharynx;  there- 
fore Ozaena  is  always  to  be  looked  for  when  there  is  a  putrid 
expectoration  (bronchitis,  gangrene  of  the  lung). 

Mouth-breathing,  which  appears  in  every  case  of  occlusion 
of  the  nose  and  nasopharynx  (by  hypertrophic  catarrh, 
polyps,  deviations  of  the  septum,  post-nasal  tumors,  etc.),  is 
often  accompanied  by  disturbing  sequelae:  snoring,  restless 
sleep  (nightmare),  inflammatory  processes  of  the  upper  air- 
passages,  disturbances  of  digestion ;  in  children,  after  a 
considerable  duration,  typical  facies  (open  mouth,  dull  ex- 
pression), deformities  of  the  teeth,  the  jaws,  even  of  the 
thorax. 

Adenoid  vegetations,  hypertrophy  of  the  lymphoid  elements  in 
the  nasopharynx  (faucial  or  3d  tonsils),  exceedingly  common  in 
children,  give  the  most  exquisite  examples  of  the  disturbances  of 
mouth-breathing.  They  are  a  frequent  source  of  deafness  and  may 
retard  the  complete  bodily  and  mental  development  of  a  child 
(aprosexia  7iasalis).  May  be  diagnosticated  by  the  child's  facial 
expression  ;  positive  diagnosis  by  the  palpation  of  nasopharynx 
with  the  index  finger. 

The  symptoms  usually  disappear  rapidly  after  the  removal  of 
the  vegetations. 

Nasal  reflex  neuroses. — These  are  reflexes  called  forth  by 
diseases  of  the  nose.  Attacks  of  migraine  and  spasms  of 
coughing,  epileptic  seizures,  etc.,  occasionally  disappear 
after  the  cure  of  nasal  affections.  The  best  known  of  these 
is  nasal  asthma :  attacks  of  bronchial  asthma  dependent 
upon  an  irritation  from  a  diseased  nose.  An  existing  asthma 
is  only  to  be  referred  to  the  nose  when  irritation  of  a  par- 
ticular spot  induces  an  attack  while  its  anaesthesia  (by  co- 
caine) stops  the  attack.  Surgical  measures  for  the  relief 
of  the  asthma  may  then  be  undertaken.  The  same  safe- 
guard of  diagnosis  should  be  applied  to  the  other  neuroses 
of  the  diseased  nose. 


V  DISEASES   OF   THE   UPrEIl   AIR-PASSAGES         109 

Throat  and  tonsils.  —  The  inspection  of  the  throat  with 
depressed  tongue  shows  whether  infectious  processes  are 
localized  there  (angina  or  diphtheria,  Chap.  II.).  At  the 
same  time,  the  presence  of  a  chronic  pharyngitis  should  be 
noted  (mucous  membrane  puffy,  reddened,  covered  with  secre- 
tion or  atrophic,  dry,  occasionally  covered  with  fine  granula- 
tions) ;  it  is  often  caused  by  the  same  elements  that  help  to 
produce  a  chronic  gastritis  (alcoholism,  too  much  smoking, 
the  eating  of  very  hot  or  poorly  masticated  food);  it  is  seen  in 
those  working  in  dust  of  any  kind,  in  speakers  and  singers. 

Insensihiidij  of  the  fauces  is  frequently  a  sign  of  hysteria  or  of 
advanced  alcoholism,  and  may  assist  in  the  diagnosis  of  a  contem- 
poraneous gastric  affection  as  neurotic  or  alcoholic.  HypercesiJiesia, 
excessive  gagging  movements  on  touching,  in  chronic  pharyngitis, 
also  frequently  in  drinkers. 

Retropharyngeal  abscess  is  recognized  by  a  fluctuating,  bulging 
mass  in  the  posterior  pharyngeal  wall ;  there  are  severe  general 
disturbance  and  high  fever.  Deglutition  and  respiration  may  be 
interfered  with.  The  threatening  symptoms  disappear  upon  the 
emptying  of  the  abscess. 

The  source  of  cryptogenetic  sepsis  should  be  sought  in  retropha- 
ryngeal abscess  and  purulent  processes  in  the  accessory  sinuses  of 
the  nose. 

General  Symptomatology  of  the  Diseases  of  the 

Larynx 

The  symptoms  of  laryngeal  diseases  are  :  — 
1.  Changes  in  the  voice.  —  In  the  great  majority  of  the 
diseases  of  the  larynx,  the  voice  is  changed.  It  becomes 
hoarse,  rough,  rasping,  indistinct  (dysphonia).  Aphonia 
(absence  of  voice,  speaking  in  whispers)  is  a  sign  of  severe 
disease  of  the  larynx  (nlceration  of  the  vocal  cords),  or  of 
imperfect  closure  of  the  glottis  (paralysis  of  the  vocal  cords). 
Falsetto  voice  is  usually  a  purely  functional  disturbance,  a 
defective  formation  of  the  voice,  Avhich  may  be  overcome  by 
methodical  exercise  in  speaking. 


110        DISEASES   OF  THE   UPPER   AIR-PASSAGES        chap. 

Ventricular  voice.  A  peculiar  rougli  and  rattling  voice 
is  i)roduced  by  the  employment  of  the  false  vocal  cords 
(ventricular  bands)  for  the  true  ones,  frequently  in  conse- 
quence of  the  disturbance  of  the  latter. 

The  nasal  voice  may  be  ojjen  or  closed.  The  former  is  due 
to  the  absence  of  the  closure  of  the  nasopharyngeal  opening 
in  consequence  of  the  paralysis  of  the  soft  palate  (principally 
after  diphtheria)  or'in  consequence  of  ulcerative  processes  of 
the  soft  palate  (generally  by  syphilis).  Test-words  for  this 
variety  are,  for  example,  pump,  mumps.  When  this  type  of 
nasal  twang  exists,  fluids  taken  into  the  mouth  will  return 
in  part  through  the  nose.  A  closed  nasal  voice  arises  from 
total  occlusion  of  the  nose  (chronic  catarrh,  polyps,  etc.). 

Diphthongia  (diplophonia)  is  the  simultaneous  production 
of  two  notes  of  different  pitch  in  speaking;  it  sometimes 
occurs  in  unilateral  paralysis  of  the  vocal  cords,  as  well  as 
in  the  presence  of  small  tumors  on  the  edge  of  a  vocal  cord 
which,  in  speaking,  are  pressed  between  the  vocal  cords. 

A  threefold  splitting  of  the  voice  is  a  rare  phenomenon,  produced 
by  pediculated  polypi  which  lie  beneath  the  glottis.  In  speaking 
they  are  first  pressed  between  the  vocal  cords  in  the  expiratory  act 
and  then  above  the  glottis.  A  prolonged  vowel  is  first  pronounced 
clearly,  then  hoarsely  and  diphthongic,  and  finally  clearly  again. 

2.  Disturbances  of  breathing.  —  The  laryngeal  diseases 
may  lead  to  dyspnoea  through  narrowing  of  the  glottis. 
Laryngeal  dyspnoea  is  inspiratory,  accompanied  by  stridor 
(a  creaking  sound  the  result  of  the  labored,  long-drawn 
breath).  The  number  of  respirations  is  diminished;  all  the 
accessory  muscles  of  inspiration  are  employed  (see  p.  125) ; 
the  sides  of  the  neck,  intercostal  spaces,  epigastrium,  are 
drawn  in.  Expiration  is  short,  inaudible.  Laryngeal  stenosis 
occurs  in  children  most  commonly  in  consequence  of  diph- 
theria (croup),  but  occasionally  through  simple  acute  laryn- 
gitis (pseudo-croup),  because  of  the  narrowness  of  the  child's 
glottis ;  in  adults  it  is  always  a  sign  of  severe  laryngeal  affec- 


V  DISEASES   OF   THE    UPPER   AlR-PASSAGES         111 

tion  (acute  oedema  of  the  glottis,  diphtheria,  bilateral  posti- 
cus paralysis,  etc.). 

Inspiratory  dyspncea  and  stridor  are  the  same  in  tracheal  as  in 
laryngeal  stenosis.     The  differential  points  are  :  — 

In  laryngeal  stenosis  the  larynx  makes  effectual  respiratory 
movements  (it  goes  upward  in  inspiration,  downward  in  expira- 
tion) ;  in  tracheal  stenosis  it  remains  quiet  or  almost  so.  The  voice 
is  usually  free  in  tracheal  stenosis;  in  laryngeal  stenosis  it  is  very 
hoarse  or  there  is  aphonia.  In  laryngeal  stenosis  the  head  is 
usually  thrown  back;  in  tracheal  stenosis  the  chin  approaches  the 
chest.     Concerning  thrills,  see  below. 

3.  Pain  in  the  larynx  is  frequently  complained  of  and  is 
described  as  tickling,  pressure,  burning,  or  soreness ;  inflam- 
matory processes,  particularly,  produce  severe  pains,  which 
radiate  toward  the  ear.  Pain  does  not  furnish  any  especial 
diagnostic  points. 

4.  Cough.  —  A  laryngeal  cough  is  sometimes  of  a  particu- 
larly loud  and  barking  character,  and  can  frequently  not  be 
distinguished  from  a  cough  emanating  from  the  lungs.  It 
is  called  the  croup  cough,  although  by  no  means  characteris- 
tic of  croup,  since  pseudo-croup  and  other  affections  are  re- 
sponsible for  coughs  of  similar  sound.  Cough  is  most  easily 
produced  from  the  posterior  wall  of  the  larynx  (intra-aryte- 
noid  region).  Irritation  of  the  ventricular  bands  and  of  the 
vocal  cords  does  not  evoke  a  cough  so  easily. 

5.  Expectoration  is  common  to  most  diseases  of  the  larynx, 
but  does  not  furnish  any  characteristic  data,  as  to  its  origin 
in  the  larynx. 

6.  Dysphagia  is  always  a  sign  of  severe  and  advanced  dis- 
ease of  the  larynx,  and  is  especially  characteristic  of  the 
involvement  of  the  epiglottis  and  the  posterior  wall.  The 
laryngeal  dyspnoea  and  the  change  in  the  voice  prevent 
diagnostic  confusion  with  difficulties  in  swallowing  caused 
by  oesophageal  stenosis.  The  changes  in  the  throat  which 
the  dysphagia  produces  are  visible. 


112         DISEASES   OF   THE    UPPER    AIR-PASSAGES       chap. 

The   External   Examination  of  the  Larynx  (Inspec- 
tion AND  Palpation) 

This  is  not  of  great  importance.  The  visible  respiratory  move- 
ments of  the  hirynx  and  their  diagnostic  significance  in  stenosis 
have  been  discussed  above. 

AVhen  stridor  is  present,  one  can  feel  a  thrill  in  that  part  of  the 
neck  occupied  by  the  trachea,  which  can  be  appreciated  alone  or 
stronger  on  expiration,  when  the  obstruction  to  respiration  lies 
deep  in  the  trachea.  Tn  laryngeal  stenosis,  on  the  other  hand,  the 
thrill  is  palpable  exclusively,  or  in  the  vast  majority  of  instances,  on 
inspiration. 

Visible  or  even  palpable  pulsation  of  the  trachea,  or  even  of  the 
entire  larynx,  has  been  described  as  a  sign  of  aneurysm  of  the 
aorta. 

The  vibrations  of  the  vocal  cords  in  speaking  may  be  felt  equally 
on  both  sides  by  placing  the  index  fingers  at  the  sides  of  the 
thyreoid  cartilages.  Weakness  of  the  vibrations  of  one  side  speaks 
for  disease  of  that  side ;  in  combination  with  other  symptoms  {e.g., 
a  threefold  division  of  the  voice,  see  above),  this  sign  may  be  the 
guide  for  a  far-reaching  diagnosis  without  the  aid  of  the  laryngo- 
scope ;  the  diagnosis  of  disease  of  the  larynx  is  usually  accom- 
plished, however,  by 

Laryngoscopic  Es^amination 

The  sunlight  or  the  light  of  a  lamp  is  thrown  upon  the  laryngeal 
mirror,  placed  obliquely  against  the  uvula,  by  a  head  mirror  or 
reflector.  The  laryngeal  mirror  then  gives  the  picture  of  the 
larynx. 

The  normal  picture  in  the  laryngeal  mirror  shows  above  (ante- 
riorly) the  epiglottis,  below  the  posterior  wall  of  the  larynx,  the 
intra-arytenoid  region,  the  two  arytenoid  cartilages,  and  above 
these,  as  a  slight  prominence,  the  cartilages  of  Santorini  and  Wris- 
berg  (cunicula  laryngis  and  cuneiform  cartilage,  respectively).  At 
the  sides,  the  picture  is  bounded  by  folds  of  mucous  membrane, 
which  extend  from  the  epiglottis  (above)  to  the  arytenoid  carti- 
lages (ary-epiglottic  ligaments)  ;  the  middle  of  the  picture  is  taken 
up  by  the  true  vocal  cords,  which  pass  antero-posteriorly  (from 
above  downwards)  and  are  divided  into  two  parts,  tlie  ligamentous, 
the  anterior  two-thirds  (formed  by  the  arytenoid  cartilages),  and 


V  DISEASES   OF   THE   UPPER  AIR-PASSAGES         ll3 

the  cartilaginous,  occupying  the  posterior  third.  The  cleft  be- 
tween the  cords  is  known  as  the  rimä  glottidis,  the  anterior  portion 
of  which  is  called  tlie  vocal  glottis,  the  posterior  the  respiratory 
glottis.  The  false  vocal  cords  (ventricular  bands)  run  parallel  to 
and  above  the  true  cords,  and  are  seen  at  the  side  in  the  picture. 
Between  the  two,  lies  the  ventricle  of  Morgagni.  The  right  vocal 
cord  appears  on  the  right  side  in  the  mirror,  the  left  on  the  left 
side;  there  is  no  transposition;  but  the  right  vocal  cord  is,  of 
course,  to  the  left  of  the  observer. 

The  laryngoscopic  examination  is  not  intended  to  estimate 
merely  the  normal  appearance  of  the  larynx,  but  above  all  the 
mobility  of  the  vocal  cords  also ;  the  patient  must  alternately 
phonate  (say  ah)  and  take  deep  inspirations.  In  phonation  the 
epiglottis  is  raised  and  the  view  into  the  larynx  facilitated.  Dur- 
ing inspiration  the  glottis  is  opened,  the  vocal  cords  are  abducted ; 
in  phonation  they  are  adducted,  the  glottis  is  closed. 

The  direct  inspection  of  the  larynx  without  a  laryngoscope  {Kir- 
stein's  autoscopy)  is  rendered  possible  by  the  use  of  the  autoscope 
when  the  uppermost  air-passages  are  rendered  straight  by  a  pecu- 
liar position  of  the  head,  when  the  root  of  the  tongue  is  pressed 
forward,  and  when  there  is  a  simultaneous  elevation  of  the  glottis. 

Normal  Functions  of  the  Muscles  and  Nerves  of 

THE  Larynx 

The  opening  of  the  glottis  is  accomplished  by  the  crico-arytenoid 
muscle,  innervated  by  the  recurrent  laryngeal  nerve;  it  acts  as  an 
abductor  by  drawing  the  vocal  process  of  the  arytenoid  cartilage 
outward. 

Closing  of  the  glottis.  The  intra-arytenoid  muscle  (arytcenoideus 
transversus  and  obliquus)  closes  the  glottis  by  drawing  the  aryte- 
noid cartilages  together ;  the  other  closers  of  the  glottis  are  the 
crico-arytenoid  lateralis,  the  principal  adductor,  which  turns  the 
vocal  process  inward,  and  thyreo-arytenoid  internus,  whose  course 
is  in  the  vocal  cords.  These  muscles  are  innervated  by  the  re- 
current nerve,  except  the  arytcenoideus  transversus,  which  receives  a 
few  fibres  from  the  superior  laryngeal  nerve. 

Tension  and  elongation  of  the  vocal  cords  are  accomplished  by  the 
crico-thyreoid  muscle,  the  nerve  supply  of  which  comes  from  the 
external  branch  of  the  superior  laryngeal  nerve  and  which  draws 
the  thyreoid  cartilage  forAvard  and  downward  toward  the  previously 
fixed  cricoid  cartilage. 
I 


114  DISEASES   OF   THE    UPPER   AIR-PASSAGES       chap. 

Tension  and  shortening  of  the  vocal  cords:  the  thyreo-arytenoid 
internus  muscle,  supplied  by  the  recurrent  nerve. 

There  are  two  laryngeal  nerves,  therefore,  the  superior  laryngeal, 
the  inferior  laryngeal,  or  recurrent,  which  are  branches  of  the 
accessory  nerve,  and  which  contain  motor  and  sensory  fibres. 

The  superior  laryngeal  nerve  supplies  with  its  small  external 
branch  the  crico-thyreoid  muscle ;  the  large  inner  branch  per- 
forates the  hyo-thyreoid  membrane  and  supplies  the  mucous  mem- 
brane with  sensory  fibres.  Its  motor  fibres  are  few  in  number, 
and  go  to  the  arytcenoideus  transversus  and  the  muscles  of  the 
epiglottis  (the  thyreo-epiglotticus,  which  raises  the  epiglottis,  and 
the  ary-epiglot/icus,  which  lowers  it). 

The  inferior  laryngeal  nerve  passes  backward  in  the  thoracic 
cavity,  on  the  right  side  encircling  the  subclavian  artery,  on  the 
left  the  arch  of  the  aorta,  passes  to  the  larynx  between  oesophagus 
and  trachea,  and  innervates  with  its  internal  branch  the  c7'ico- 
arytcenoideus  posticus  and  the  arytcenoideus  tr-ansversus  muscles,  and 
with  its  external  branch  all  the  remaining  muscles  of  the  larynx. 

Symptoms  of  the  Most  Importaxt  Diseases  of  the 

Laryxx 

Acute  laryngitis.  —  Usually  no  fever  (in  children,  irreg- 
ular remittent  fever).  Hoarseness  and  pain  in  the  throat; 
slight  difficulty  in  swallowing.  Mucous  or  niuco-purulent 
expectoration,  not  characteristic.  Laryngoscopic  examina- 
tion: redness  and  swelling  of  the  mucous  membrane,  dif- 
fuse or  circumscribed.  Vocal  cords  reddened,  occasionally 
superficial  erosions.  Vocal  cords  apparently  small  in  conse- 
quence of  the  swelling  of  the  ventricular  bands. 

Chronic  laryngitis.  —  Pressure,  scratching,  etc.,  in  the  lar- 
ynx, especially  in  singing,  smoking,  etc. ;  speech  thick, 
honrse ;  aphonia  after  continued  speaking.  Scanty,  muco- 
purulent sputum.  Laryngoscopic  examination :  dh'ty  gray^- 
red  discoloration  of  the  vocal  cords,  profuse  secretion, 
occasional  swelling  of  the  follicles  of  the  mucous  membrane 
to  the  size  of  a  grain  of  sand  (laryngitis  granulosa  or  foil i- 
cuhiris).  Yevj  often,  callous  thickening,  grayish-red  in 
color,  of  the  posterior  wall  of  the  larynx. 


V  DISEASES   OF   THE   UPPER   AIR-PASSAGES         115 

Tuberculosis  of  the  larynx. — Usually  secondary  to  pul- 
monary phthisis.  Hoarseness,  aphonia,  pain,  dysphagia. 
Laryngoscopic  examination,  —  1st  stage  :  tubercular  infiltra- 
tion. Mucous  membrane,  puffy,  swollen,  x^ale,  oedematous. 
2d  stage:  tubercular  ulceration.  Irregular,  confluent  swell- 
ings with  jagged,  raised  edges,  passing  into  the  depths.  The 
pit  of  the  ulcer  covered  with  purulent  secretion  in  which 
tubercle  bacilli  are  present.  Sites  of  predilection  for  tuber- 
cular changes  are,  first,  the  arytenoid  cartilages  and  the 
intra-arytenoid  space,  next,  the  true  and  false  vocal  cords. 

Syphilis  of  the  larynx. — The  complaints  and  subjective 
symptoms  are  usually  not  characteristic.  Laryngoscopically 
one  may  differentiate.  1.  Early  forms  (secondary  phenom- 
ena) :  erythema  of  the  larynx,  sharply  limited  red  spots ; 
syphilitic  laryngitis,  usually  not  to  be  distinguished  from 
non-specific  chronic  inflammation  (history  and  examination 
for  other  syphilitic  lesions,  especially  in  the  throat) ;  pap- 
ules, grayish- white,  flat  elevations  on  the  inflamed  mucous 
membrane  (mucous  patches) ;  superficial  ulcerations  (sites 
of  predilection :  epiglottis,  especially  its  border  and  lingual 
surface,  the  vocal  cords).  2.  Late  forms  (tertiary  phe- 
nomena) :  circuniscribed  gummata  and  diffuse  gummatous 
infiltrations  characterized  by  rapid  necrosis ;  the  ulcers 
following  the  necrosis  are  deep  and  are  sharply  limited, 
but  can  not  always  be  easily  distinguished  from  tubercular 
ulcers.  The  differential  diagnosis  is  established  by  the 
demonstration  of  an  existing  pulmonary  phthisis  (tubercle 
bacilli  in  the  sputum),  or  of  a  previous  syphilitic  infec- 
tion ;  in  doubtful  cases  by  the  result  of  anti syphilitic  treat- 
ment. Luetic  ulcers  may  become  very  important  by  the 
strong  contraction  of  radiating  scars,  which  may  be  the 
source  of  very  severe  laryngeal  stenosis. 

Tumors  of  the  larynx.  — usually  involving  the  true  or  false 
vocal  cords,  pediculated  (polyps)  or  sessile.  Symptoms 
dependent  upon  the  size  and  situation  of  the  growth ;  there 


116  DISEASES   OF   THE   UPPER   AIR-PASSAGES       chap. 

is  usually  lioarseness,  ofteu  the  sensation  of  a  foreign  body, 
pain,  dyspnoea,  sometimes  dysphagia.  It  is  essential  to 
differentiate  betvreen  benign  and  malignant  growths  (carci- 
noma, rarely  sarcoma).  The  benign  tumors,  frequently 
with  a  smooth  surface,  are  always  circumscribed ;  carcinoma, 
on  the  contrary,  usually  not  sharply  limited,  of  irregular 
form,  soon  ulcerating ;  swelling  of  the  lymph-glands  demon- 
strable. The  motility  of  the  vocal  cords  soon  diminished 
in  the  presence  of  a  malignant  growth.  Age  and  condition 
of  patient's  strength  important.  Diagnosis  often  difficult, 
especially  in  the  early  stages,  in  which  it  is  important  on 
account  of  the  therapeutic  measures.  Usually  a  positive 
diagnosis  can  be  made  only  by  the  microscopic  examination 
of  a  small  piece  of  the  tumor  secured  by  excision.  The 
special  anatomical  diagnosis  of  benign  tumors  (fibroma, 
papilloma,  myoma,  adenoma,  etc.)  is  only  to  be  made  b}'  the 
microscopic  examination  after  extirpation  or  the  removal 
of  a  small  piece  by  excision. 

Pachydermia  laryngis  are  wart-like  thickenings  on  the 
most  yjosterior  parts  of  the  vocal  cords,  usually  containing 
a  depression  on  the  surface,  occasionally  with  gaps  or 
clefts,  and  then  not  unlike  carcinoma ;  usually  accompanies 
chronic  catarrh. 

Spasm  of  the  glottis  flaryngo-spasm) :  spasmodic  closure 
of  the  glottis  leading  to  the  point  of  suffocation  and  uncon- 
sciousness. In  children,  stands  in  etiological  relation  to 
rachitis ;  in  adults,  usually  caused  by  hysteria,  but  may 
be  due  to  organic  disease  of  the  central  nervous  system 
(laryngeal  crises  of  locomotor  ataxia). 

Paralysis  of  the  Vocal  Cords 

When  of  peripheral  origin,  paralysis  of  the  vocal  cords 
may  be  produced, by  pressure  upon  the  recurrent  nerve  (by 
goitre,  aneurysm  of  the  aorta,  carcinoma  of  the  oesophagus, 


DISEASES   OF   THE    UFPER   AIR-PASSAGES 


IIT 


enlarged  lymph-glands,  tumors 
of  the  mediastinum,  pericardi- 
tis), or  in  consequence  of  a  neu- 
ritis (alcoholic  or  rheumatic) ; 
of  ceiitral  origin :  hysteria  (func- 
tional paralyses  of  the  larynx), 
or  as  a  result  of  organic  disease 
of  the  nucleus  of  the  accessory 
nerve  in  the  floor  of  the  4th 
ventricle  (in  locomotor  ataxia, 
multiple  sclerosis,  bulbar  pa- 
ralysis, syringomyelia,  cerebral 
syphilis,  etc.). 

Differentiation :  1.  Paralysis 
of  the  abductors  of  the  vocal 
cords. — Paralysis  of  the  exter- 
nal abductors  (  crico  -  thyreoid 
muscle)  recognized  by  palpation 
of  the  space  between  the  thy- 
reoid and  cricoid  cartilages  ;  the 
normal  approach  of  the  two  in 
Phonation  is  absent.  The  glottis 
is  not  tense ;  it  appears  as  a 
wavy  line ;  voice  hoarse. 

This  is  a  paralysis  of  the 
superior  laryngeal  nerve  (most 
frequently  a  post-diphtheritic 
paralysis),  in  which  the  depres- 
sors of  the  epiglottis  do  not  act 
(epiglottis  immovable,  usually 
directed  toward  the  root  of  the 
tongue),  and  the  sensibility  of 
the  mucous  membrane  of  the 
larynx  is  lost.  These  three 
factors   (elevation   of   the    epi- 


Bilateral    paralysis   of 
the  recurrens. 


Paralysis  of  thyreo- 
arytenoid  and  intra- 
arytenoids. 


Paralysis  of  the  intra- 
arytenoids. 


Paralysis  of  the   thy- 
reo-arytenoids. 


Bilateral    paralysis   of 
the  posticus. 


Fig.  25. 


118  DISEASES   OF   THE   UPPER   AIR-PASSAGES       chap. 

glottis,  ansesthesia  of  the  mucous  membrane,  atony  of  the 
glottis)  are  responsible  for  the  dangers  of  mistakes  in  swal- 
lowing (foreign-body  pneumonia). 

2.  Paralysis  of  the  adductors  of  the  glottis.  —  The  paraly- 
sis of  the  adductors  is  usually  functional.  The  glottis 
stands  widely  open  (inspiratory  position  through  action  of 
the  antagonistic  muscles),  when  all  three  adductors  are 
attacked  (crico-arytoenoideus  lateralis,  thyreo-arytcenoideus  in- 
ternus, and  arytoenoideus  transversus  —  complete  paralysis 
of  the  adductors).  The  glottis  then  has  the  form  of  a  tri- 
angle, in  consequence  of  which  there  is  no  interference  w^ith 
respiration,  but  complete  aphonia  exists. 

Isolated  paralysis  of  the  arytoenoideus  transversus  muscle 
(frequent  in  acute  catarrh  and  hysteria)  shows  the  cartilagi- 
nous portion  of  the  glottis  gaping  as  a  small  triangle  while 
the  anterior  part  of  the  glottis  closes  in  phonation.  Hoarse- 
ness, even  aphonia,  Avithout  dyspnoea,  supervenes. 

Exclusive  paralysis  of  the  crico-arytcenoideus  lateralis  is  very 
rare  and  scarcely  to  be  diagnosticated  positively.  On  pho- 
nation a  small  cleft  of  the  glottis  near  the  vocal  processes 
remains  open ;  the  disturbance  of  the  voice  is  meagre. 

Paralysis  of  the  thyreo-arytcienoidei  interni  is  the  most 
frequent ;  on  phonation  a  small  oval  of  the  glottis,  especially 
in  its  centre,  remains  open ;  the  edges  of  the  poorly  vibrating, 
narrow  vocal  cords  appear  excavated;  the  voice  is  aphonic; 
no  dyspnoea.  This  type  of  paralysis  is  common  as  an  occu- 
pationcd  neurosis  (singers,  public  speakers,  etc.),  and  usually 
presents  the  jjicture  of  hysterical  aphonia  (rarely  total  paraly- 
sis of  the  adductors). 

Functional  hysterical  aphonia  may  be  recognized  by  its  sudden 
appearance  and  disappearance  (intermittent  aphonia  is  almost 
ahvays  hysterical).  It  may  accompany  psychical  disorders;  the 
cough  usually  lias  a  ringing  tone.  Mere  pressure  upon  the  thy- 
reoid cartilages  produces  the  peculiar  tone  of  the  cough.  The  his- 
tory and  tlie  other  symptoms  render  the  diagnosis  that  of  hysteria. 


V  DISEASES   OF  THE   UPPER   AIR-PASSAGES         119 

3.  Paralysis  of  the  abductors  of  the  glottis  (jyosticus 
paralysis).  —  The  paralysis  of  these  muscles  is  always  or- 
ganic, never  functional.  In  paralysis  of  the  crico-arytce- 
nokleus  i^osticus  muscle,  the  vocal  cord  lies  in  the  median 
line,  through  the  action  of  antagonistic  muscles ;  phonation 
is  therefore  more  or  less  intact. 

Unilateral  abductor  paralysis :  no  dyspnoea;  voice  some- 
times rattling  and  not  clear,  more  frequently  intact ;  no 
symptoms  then  arise,  but  the  paralysis  is  accidentally  dis- 
covered (in  syringomyelia,  tabes  dorsalis,  etc.). 

Bilateral  abductor  paralysis :  both  vocal  cords  immovable, 
lying  in  or  very  near  the  median  line  (stenosis  of  the  glottis)  ; 
voice  almost  normal,  but  severe  inspiratory  dyspnoea  with 
stridor.  Expiration  easy.  The  closely  lying  vocal  cords 
approach  each  other  more  closely  in  inspiration.  Trache- 
otomy necessary. 

4.  Paralysis  of  the  recurrent  laryngeal  nerve.  —  If  all  the 
branches  of  the  recurrent  nerve  are  paralyzed,  adduction 
and  abduction  stopped,  the  vocal  cords  take  a  position 
between  the  two  :  cadaveric  position. 

Unilateral  paralysis  of  the  recurrent  nerve.  The  paralyzed 
vocal  cord  in  cadaveric  position  mth  excavated  edge ;  the 
arytenoid  cartilage  dropped  forward  toward  the  interior  of 
the  larynx;  the  unaffected  cord  often  passes  beyond  the 
median  line  in  phonation,  so  that  a  closure  of  the  oblique 
glottis  supervenes  (over-riding  of  the  arytenoid  cartilages)  ; 
voice  weak,  with  no  ring ;  no  dyspnoea. 

Bilateral  paralysis  of  the  recurrent  nerve.  Both  vocal  cords 
in  cadaveric  position,  glottis  widely  opened  in  the  same 
position  in  phonation  and  respiration.  Absolute  ajyJionia 
(cough  and  expectoration  -weak,  and  with  little  sound) ;  no 
dyspnoea. 

In  the  recurrent  nerve,  the  adductor  and  abductor  fila- 
ments lie  separated.  The  abducting  nerves  are  physiologi- 
cally more  sensitive  than  the  adductors.      All  influences 


120        DISEASES   OF   THE    UPPER   AIR-PASSAGES     chap,  v 

which  lead  to  recurrent  paralysis  (goitres,  aneurysms,  etc., 
see  above)  frequently  cause  a  primary  abductor  paralysis 
which  after  a  longer  or  shorter  time  (sometimes  years) 
passes  into  a  recurrent  paralysis  as  soon  as  the  adductor 
part  of  the  nerve  suffers  from  the  disease. 


CHAPTER  VI 

THE  DIAGNOSIS  OF  DISEASES  OF  THE  RESPIRATORY 

TRACT 

In  the  history  of  the  patient,  particular  stress  must  be  laid 
upon  hereditary  taint  when  tuberculosis  is  suspected.  The  so-called 
scrofulous  affections  of  childhood  and  previous  pulmonary  dis- 
eases are  important,  as  are  hcematemeses  and  inflammations  of  the 
bones  or  joints  of  a  probable  tubercular  origin.  The  occupation 
(stone-cutters,  coal-miners,  compositors,  etc.)  must  also  be  taken 
into  account,  and  sometimes  a  weakening  condition,  such  as  a  re- 
cent Puerperium,  may  offer  a  basis  for  pulmonary  invasion.  When 
lung  trouble  of  gradual  origin  is  before  the  physician,  the  early 
symptoms  of  phthisis  pulmonalis  must  be  looked  for. 

The  attention  of  the  physician  is  directed  toward  the 
respiratory  apparatus  on  complaint  of  ^xiin  in  the  side  of  the 
chest,  cough,  and  expectorcition  or  dyspnoea. 

Pain  in  the  side  is  caused  mainly  by  affections  of  the  pleura,  and 
calls  for  an  examination  of  the  thorax.  In  differential  diagnosis, 
it  is  not  particularly  valuable,  since  a  mild  pleurisy  may  accompany 
many  other  thoracic  diseases. 

Although  pain  in  the  chest  may  be  called  forth  by  some  cardiac 
affection  or  bv  a  muscular  rheumatism,  it  demands  a  careful  diao-- 
nostic  examination.  It  may  occur  in  any  part  of  the  chest,  and 
may  be  described  by  the  patient  as  a  pressing  or  drawing  pain. 

A  cough  is  almost  invariably  a  sign  of  disease  of  the  respiratory 
apparatus.  It  is  reflex  in  its  nature,  and  is  caused  by  an  irritation 
of  the  mucous  membrane  of  the  larynx,  trachea,  or  bronchi  by  an 
accumulation  of  secretion.  It  can  not  arise  from  the  alveoli  of  the 
lungs,  although  irritation  or  inflammation  of  the  pleura  may  pro- 
duce it.  Occasionally  a  cough  may  be  induced  by  an  irritation  of 
the  pharynx,  oesophagus,  stomach,  liver,  or  spleen. 

The  Jcind  of  cough  may,  at  times,  be  of  diagnostic  significance. 

121 


122  DISEASES   OF   THE   KESPIRATORY   TRACT       chap. 

It  is  iiiiportant  to  notice  the  number  of  coughs  that  succeed  each 
other  in  each  attack.  The  so-called  hacking  cough  is  common  in 
incipient  phthisis,  and  may  direct  the  physician's  attention  to  the 
latent  disease.  The  cough  oi pertussis  is  characteristic,  and  is  seldom 
heard  in  other  pulmonary  diseases.  It  consists  of  a  great  number 
of  coughs  rapidly  following  each  other  and  interrupted  by  deep, 
sighing,  stridulous  inspirations.  A  drg  or  moist  cough,  a  hard  or 
loose  cough,  give  indications  as  to  the  amount  and  character  of 
secretion  and  as  to  the  progress  of  the  disease.  The  pitch  and  noise 
made  by  a  coughing  patient  will  sometimes  allow  an  estimate  to 
be  made  of  his  general  condition.  A  particularly  loud,  barking 
cough,  for  instance,  is  characteristic  of  inflammation  of  the  larynx 
and  trachea.  A  differential  diagnosis,  except  in  pertussis,  can 
rarely  be  made  from  the  mere  symptom,  cough  ;  but  the  intensity 
of  a  pulmonary  lesion,  or  its  progress,  may  be  recognized  by  the 
cough.  Cardiac  diseases  sometimes  engender  a  cough  after  a  sec- 
ondary pulmonary  congestion  has  arisen. 

Of  the  greatest  importance  in  the  diagnosis  of  diseases  of  the 
lungs  is  the  expectoration  or  sputum.  It  must  not  be  forgotten,  how- 
ever, that  a  catarrh  of  the  nose  or  throat  may  be  responsible  for 
expectorated  material,  brought  forth  by  hawking.  Sputum  w'hich 
is  expectorated  by  a  cough  comes  from  the  larynx,  the  trachea, 
the  bronchi,  or  from  an  ulcerating  process  in  the  lungs.  Although 
the  examination  of  the  sputum  usually  concludes  the  examination 
of  the  respiratory  organs,  it  is  as  well  to  take  note  of  pathological 
peculiarities  at  once;  as,  for  instance,  bloody  sputum  or  sputum  of 
rusty-red  or  green  color;  balls  of  sputum  or  expectoration  that 
sinks  in  water,  etc. 

Inspectioist  of  the  Thorax 

The  inspection  of  the  thorax  gives  information :  1.  As  to 
the  normal  shape  or  deformity  of  the  chest. 

Curvatures  of  the  spine  have  a  diagnostic  importance,  since 
they  are  etiological  factors  in  some  diseases  of  the  lungs : 
through  the  compression  of  parts  of  the  lungs  and  the  com- 
pensatory emphysema  of  other  parts ;  in  the  course  of  time 
this  may  be  followed  by  dilatation  of  the  right  ventricle, 
and  cyanosis  and  dyspnoea  in  consequence  of  the  diminished 
circle  of  the  pulmonary  circulation. 


VI  DISEASES   OF   TUE    RESPIRATORY   TRAGT  123 

Kyphosis  is  the  term  applied  to  a  posterior  spinal  curvature,  and 
is  known  as  (jlhhus  ^vhen  it  forms  an  acute  angle.  A  forward  cur- 
vature is  known  as  lordosis,  while  a  lateral  curvature  is  called  scoli- 
osis. The  most  common  form  is  tbe  combination  of  kyphosis  and 
scoliosis ;  i.e.,  a  simultaneous  lateral  and  posterior  curvature. 

Anomalies  of  the  sternum  have  little  diagnostic  importance,  as 
they  do  not  produce  pulmonary  lesions.  The  xiphoid  process  may 
be  pressed  inward  in  the  persons  of  men  who,  in  their  occupation, 
hold  tools  or  implements  against  it,  as  shoemakers.  A  deep  sink- 
ing in  of  the  lower  part  of  the  sternum  gives  rise  to  the  funnel- 
shcrped  chest;  it  is  a  congenital  deformity,  and  is  usually  associated 
with  other  physical  or  mental  abnormalities.  A  pigeon  breast  or 
wedge-shaped  breast  {pectus  carimitum)  is  caused  by  rachitis  by 
the  compression  of  the  costal  cartilages.  In  this  manner  the 
sternum  is  pushed  forward  and  assumes  the  shape  of  a  wedge. 

The  angular  eminence  seen  in  many  individuals  between  the 
manubrium  and  the  body  of  the  sternum  is  described  as  the  angle 
of  Ludwig  (angulus  Ludovici).  The  average  length  of  the  sternum 
in  the  adult  is  from  16  to  20  cm. 

%  Of  great  diagnostic  value  is  the  circumference  of  the 
chest,  —  normal,  diminished  or  enlarged;  and  it  is  important 
to  note  whether  the  enlargement  or  diminution  exists  on 
one  or  both  sides. 

a.  A  bilateral  increase  in  the  circumference  of  the  thorax 
presents  a  characteristic  picture ;  the  chest  is  very  broad, 
but  seems  shortened.  It  is  knowai  as  the  barrel-shaped 
chest,  —  and  is  pathognomonic  for  emphy^sema  (vohimen  jnd- 
mo7ium  auctum).  Although  the  enlargement  includes  all 
the  thoracic  diameters,  the  antero-posterior  is  mainly  deep- 
ened.    The  thorax  is  in  a  position  of  permanent  inspiration. 

The  entrance  of  air  or  üuid  into  the  pleural  cavity  of 
either  side  may  produce  an  enlargement  of  that  half  of  the 
thorax.  The  affected  side  usually  lags  behind  in  the  respi- 
ratory movements.  An  unilateral  enlargement  occurs  in 
pneumothorax  and  pleurisy  with  effusion,  less  often  accom- 
panying mediastinal  tumors. 

b.  A  bilateral  retraction  of  the  chest-^valls  is  usuallv  con- 


124  DISEASES   OF   THE    RESPIRATORY   TRACT       chap. 

genital.  The  thorax  is  long,  flat,  and  narrow,  the  antero- 
posterior diameter  is  diminished,  and  the  intercostal  spaces 
are  broad,  This  form  of  thorax  has  been  described  as  a  para- 
lytic thorax,  and  generally  arouses  the  suspicion  of  phthisis. 
An  unilateral  retraction  of  the  thoracic  parietes,  or  better, 
perhaps,  a  sinking  in  of  one  side,  is  found  after  the  absorp- 
tion of  pleuritic  exudates  and  in  the  shrinking  of  tubercular 
lungs  (cirrhosis  pulmonum). 

Measurements  of  the  tliorax.  Dilatation  or  narrowing  can  usually 
be  estimated  quite  distinctly  with  the  naked  eye;  but  it  is  some- 
times necessary,  in  order  to  establish  the  circumference  or  meas- 
urements of  the  chest,  to  employ  a  tape-measure  or  a  cyrtometer. 

The  mean  average  measurements  of  the  thoracic  circumference 
in  a  healthy  adult  man,  estimated  at  the  point  of  greatest  expan- 
sion, are  82  cm.  after  deepest  expiration  and  90  cm.  after  deepest 
inspiration.  This  is,  of  course,  only  approximate,  and  varies 
largely  in  individuals.  In  general,  it  may  be  said  that  the  circum- 
ference of  the  chest  at  the  nipple  after  deepest  expiration  should 
equal  one-half,  at  least,  of  the  body's  length.  The  right  half  of 
the  chest  may  be  from  0.5  to  2  cm.  larger  in  a  right-handed  person 
than  the  left  side,  and  vice  versa.  The  thoracic  diameters  in 
women  are  somewhat  less  than  the  corresponding  ones  in  men. 

The  sterno-vertebral  diameter,  measured  with  the  cyrtometer, 
averages  in  adult  men  superiorly  16.5,  inferiorly  19.2  cm.  The 
lateral  diameter  at  the  level  of  the  nipple  (costal  diameter),  26  cm. 
In  women  all  these  diameters  are  diminished. 

3.  The  frequency,  type,  and  rhythm  of  the  respiratory 
movements  may  be  appreciated  by  inspection. 

The  normal  number  of  respirations  varies  from  16  to  20;  in  the 
new-born  from  40  to  44.  The  normal  relation  between  pulse  and 
respiration  is  1  to  3.5  or  1  to  4. 

The  lungs  remain  completely  passive  in  respiration,  merely  fol- 
lowing the  motion  of  the  ribs  and  diaphragm.  In  men  the  inspi- 
ratory expansion  is  due  largely  to  the  contraction  of  the  diaphragm, 
and  is  known  as  the  costo-ahdominal  type  of  breathing.  The  costal 
type  is  found  in  women  in  whom  inspiration  is  principally  accom- 
plished by  the  elevation  of  the  ribs  by  the  intercostal  and  scaleni 
muscles. 


VI  DISEASES   OF   THE    RESPIRATORY  TRACT  125 

An  increased  frequency  and  deepening  of  respiration 
(dyspnoea)  is  often  caused  by  cardiac  diseases  and  extensive 
abdominal  distention. 

Dyspnoea  is  to  be  referred  to  some  pulmonary  lesion  when 
there  is  simultaneous  cough  and  expectoration  or  pain  in  the 
side  or  other  parts  of  the  chest.  It  is  a  symptom  of  pneu- 
monia, when  accompanied  by  high  fever  and  rubiginous 
sputum ;  it  occurs  in  pleurisy  and  pneumothorax  with  im- 
paired mobility  and  expansion  of  the  affected  side;  it  is 
seen  in  emphysema  in  connection  with  a  barrel-shaped 
chest  and  diffuse  bronchial  rales  over  both  lungs ;  it  is 
observed,  finally,  in  advanced  phthisis  {habitus  paralyticus). 

Dyspnoea  which  appears  in  a  tubercular  subject  in  an  early  stage 
of  the  disease  is  significant  of  some  complication  which  must  be 
recognized ;  as,  empyema,  pleurisy,  pneumothorax,  or  miliary 
tuberculosis. 

The  kinds  of  dyspnoea.  Inspiratory  and  expiratory  dyspnoea  are 
recognized.  In  inspiratory  dyspnoea  the  accessory  muscles  of  in- 
spiration (the  sterno-cleido-mastoid,  scaleni,  levatores  costarum, 
pectorales  major  and  minor,  levatores  scapul?e,  rhomboidei,  tra- 
pezii,  and  erectores  trunci)  are  tetanically  contracted.  In  extreme 
cases  there  is  a  retraction  of  the  lower  ribs  and  of  the  space  just 
below  the  ensiform  appendix.  Stenosis  of  the  larynx,  trachea,  or 
bronchi  may  call  forth  a  high  grade  of  inspiratory  dyspnoea. 

In  expiratory  dyspnoea,  expiration  is  prolonged  and  difficult. 
The  abdominal  muscles,  the  quadratus  lumborum,  and  the  serratus 
posticus  inferior  act  as  accessory  muscles.  This  variety  of  dyspnoea 
is  found  principally  in  emphysema  and  bronchial  asthma. 

The  dyspnoea  most  commonly  seen  is  a  mixture  of  expiratory 
and  inspiratory  "  air-hunger." 

Asthma  is  that  form  of  difficult  breathing  in  which  dyspnoea 
appears  in  attacks  lasting  at  times  for  hours  and  followed 
by  a  longer  or  shorter  period  of  quiet,  natural  respiration. 
Its  most  common  form  is  bronchial  asthmct,  probably  of  neu- 
rotic origin,  which  produces  in  apparently  healthy  individ- 
uals a  temporary  expiratory  dyspnoea  of  the  most  intense 
kind.     During  such  an  attack  the  diaphragm  is  tetanically 


126         DISEASES  OF  THE   RESPIRATORY  TRACT       cnxP. 

contracted,  the  liver  dulness  is  lower  than  normal,  and  dif- 
fuse, sibilant  rales  may  be  heard.  At  the  end  of  the  attack 
a  small  quantity  of  characteristic  sputum  is  expectorated 
(see  below).  The  pulse  remains  regular  and  strong  during 
the  attack.  The  prognosis  after  a  single  seizure  is  good  so 
far  as  life  is  concerned  ;  oft-repeated  onsets  lead  to  the 
development  of  emphysema. 

In  striking  contrast  to  bronchial  asthma  are  the  dyspnoeic 
attacks  in  cardiac  diseases  (cardiac  asthma).  In  these  cases 
the  pulse  becomes  small  and  irregular  and  the  left  ventricle 
is  dilated.     The  prognosis  must  always  be  doubtful. 

Nasal  asthma  is  spoken  of  when  attacks  of  bronchial  asthma 
are  evolved  by  reflex  irritation  of  a  pathological  nasal  mucous  mem- 
brane (p.  108).  Dyspeptic  asthma  is  the  name  given  to  attacks  of 
fear  and  anxiety  in  persons  suffering  from  nervous  dyspepsia.  (Tn 
these  instances  one  has  usually  to  do  with  a  neurasthenic.)  Unemic 
asthma  consists  of  the  attacks  of  dyspnoea  occurring  in  chronic 
nephritis,  which  are  probably  in  reality  cardiac  asthma.  Hay-fever 
produces  attacks  of  dyspnoea  in  otherwise  healthy  persons.  It  is 
probably  caused  by  irritation  of  the  nasal  mucous  membrane  by 
the  pollen  of  certain  grasses. 

Spirometry 

By  inspection  one  may  conclude  as  to  the  spirometry  ; 
that  is,  the  determination  of  the  quantity  of  air  given  off  b}^ 
the  deepest  possible  expiration  after  the  deepest  possible 
inspiration  (vital  capacity).  The  vital  capacity  is  diminished 
in  all  diseases  of  the  respiratory  organs. 

The  diagnostic  value  of  this  measure  is  unimportant,  since 
there  are  no  characteristic  differences  in  the  vital  capacity 
among  the  various  lung  diseases. 

On  the  other  hand,  how^ever,  spirometry  is  of  real  value 
in  judging  of  the  improvement  or  aggravation  of  a  disease, 
particularly  with  reference  to  the  influence  of  the  therapeu- 
tic measures  involved. 


VI  DISEASES   OF   THE    RESPIRATORY   TRACT         127 

The  vital  capacity  is  measured  by  Hutchinson's  spirometer.  lu 
healthy  men  it  varies  from  3000  to  4000  c.c,  an  average  of  3600 
c.c. ;  in  healthy  women  it  lies  between  2000  and  3000,  an  average 
of  2500  c.c.  The  vital  capacity  increases  with  the  ])odily  length, 
each  centimetre  of  the  latter  representing  about  2'1  c.c.  of  the 
former.     In  children  and  in  the  aged  it  is  diminished. 

Complementary  air  is  that  whicli  may  be  drawn  into  tlie  lungs 
by  the  deepest  inspiration  after  an  ordinary  inspiration.  It  is 
about  1500  c.c. 

Reserve  air  is  that  which  may  be  expired  by  the  deepest  expira- 
tory effort  after  ordinary  expiration.     It  equals  about  1500  c.c. 

Breathing  or  tidal  air  is  the  air  ordinarily  changed  by  each  act 
of  resjDiiation.     It  amounts  to  about  500  c.c. 

Residual  air  is  the  air  remaining  in  the  lungs  after  the  most  vio- 
lent expiratory  effort.     It  is  estimated  at  from  1600  to  2000  c.c. 

After  the  tliorongli  consideration  of  the  conclusions 
reached  by  the  inspection  of  the  thorax  and  its  move- 
ments, the  physical  examination  of  the  respiratory  organs  is 
undertaken :  the  ijercussion  and  auscultatioyi  of  the  thorax. 

Mensuration 

The  topographical  data  which  enhance  the  ease  of  the  determi- 
nation of  the  height  and  breadth  of  the  chest  are  here  given. 

The  height  of  the  chest  is  anteriorly  determined  by  the  clavicle  or  by 
the  supra-  and  infra-clavicular  spaces.  The  external  border  of  the 
latter  includes  the  space  of  Mohrenheim.  Below  the  clavicle  the  ribs 
are  employed.  The  2d  rib  is  the  starting-point  in  counting,  since 
it  can  be  easily  recognized  by  its  attachment  to  the  sternum  (angle 
of  Ludwig) .  The  nipple  usually  lies  over  the  -Ith  rib  or  in  the  4th 
intercostal  space,  usually  about  10  cm.  distant  from  the  edge  of  the 
sternum.  At  the  level  of  the  xiphoid  or  ensiform  process  a  distinct 
furrow  usually  traverses  the  thorax,  which  marks  the  site  of  inser- 
tion of  the  diaphragm  (^Harrison's  fmn-ow).  The  region  beneath 
this  furrow  to  the  arch  of  the  ribs  is  the  hypochondrium.  The 
determination  of  the  height  of  the  chest  posteriorly  is  aided  by 
using  the  spine  of  the  scapula  as  a  landmark;  by  this  means 
the  7th  cervical  vertebra  (vertebra  prominens^  is  easily  felt.  The 
other  guiding-point  is  the  scapula,  which  covers  the  space  from  the 
2d  to  the  7th  or  from  the  od  to  the  Sth  ribs  and  which  is  divided  by 


128  DISEASES   OF   THE   KESPIRATORY  TRACT       chap. 

its  spine  into  the  supra-  and  infra-spinoiis  fossse.  The  space  be- 
tween the  internal  borders  of  the  scapulae  is  the  inter-scapular  space. 
For  the  determination  of  the  width  of  the  thorax,  the  following 
imaginary  lines,  drawn  parallel  to  the  long  axis  of  the  body,  are 
used :  — 

1.  The  sternal  line,  representing  the  borders  of  the  sternum  or 

the  attachments  of  the  ribs. 

2.  The  para-sternal  line,  midway  between  the  sternal  line  and 

the  nipple. 

3.  The  mamillary  line,  drawn  through  the  nipple. 

4.  The  anterior  axillary  line,  drawn  through  the  anterior  border 

of  the  axilla  (pectoralis  major). 

5.  The  middle  axillary  line  is  drawn  through  the  middle  of  the 

axilla. 

6.  The  posterior  axillary  line  is  drawn  through  the  posterior  bor- 

der of  the  axilla  (latissimus  dorsi). 

7.  The  scapular  line,  drawn  through  the  inferior  angle  of  the 

scapula. 

The  linea  costo-articularis  is  drawn  from  the  claviculo-sternal 
articulation  to  the  apex  of  the  11th  rib. 

Topography  of  the  individnal  lobes  of  the  lungs.  The  right 
lung  has  3  lobes,  the  left  but  2.  The  right  upper  and  right 
lower  lobes  may  be  made  out  posteriorly  on  the  right  side. 
The  border  between  them  begins  at  the  level  of  the  2d  or 
3d  rib.  This  border  is  divided  about  6  cm.  above  the  angle 
of  the  scapula  into  two  fissures  which  enclose  the  middle 
lobe.  The  superior  fissure  is  directed  almost  horizontally 
forward  and  reaches  the  anterior  border  of  the  lung  at  the 
level  of  the  4th  and  5th  costal  cartilages.  The  inferior  fis- 
sure is  directed  perpendicularly  downward  and  reaches  the 
inferior  border  of  the  lung  in  the  mamillary  line.  Hence  we 
have  :  right  side,  anteriorly,  upper  lobe  as  far  as  the  3d  rib ; 
below  that,  middle  lobe.  On  the  leß  side  posteriorly,  upper 
lobe  as  on  the  right  side.  The  border  extends  without  bifur- 
cation obliquely  forward  and  ends  in  the  mamillary  line  at 
the  6th  rib.  Hence  we  have :  left  side,  posteriorly,  upper  and 
lower  lobes;  anteriorly  only  the  upper  lobe  (and  the  heart). 


VI  DISEASES   OF   THE    KESriKATOKY   TRACT  129 

Percussion  of  thp:  Thorax  ^ 

By  the  perciissiou  of  different  areas  over  the  thorax, 
characteristic  differences  in  sound  may  be  appreciated  ac- 
cording as  the  thoracic  organs  contain  more  or  less  air. 

Percussion  serves  to  determine  :  — 

1.  The  borders  of  the  air-containing  lungs    as    differen- 

tiated from  other  organs  (as  the  liver,  the  heart). 

2.  The  amount  of  air  contained  in  the  lungs,  which  dif- 

fers characteristically  in  diseases  of  these  organs. 

The  qualities  of  sound  obtained  by  percussion  are  :  — 

1.  Clear  or  dull  =  loud  and  low. 

2.  High  and  low  (pitch). 

3.  Tympanitic  and  non-tympanitic. 

One  obtains  a  clear  (loud)  non-tympanitic  note  over  the 
lungs ;  a  clear  (loud)  tympanitic  note  over  gastric  and  in- 
testinal areas  ;  a  dull  note  over  the  heart,  the  liver,  the 
spleen.  High  and  low  are  qualities  referred  only  to  tym- 
panitic sounds  (as  over  cavities). 

Characteristic  qualities  of  sound  are:  the  metallic  sound 
and  the  cracked-pot  sound  (bruit  depot  fele). 

It  is  essential  for  the  beginner  to  practise  percussion  frequently 
on  healthy  persons,  in  order  to  drill  his  ear  to  the  different  quali- 
ties of  the  clear  (normal)  notes  obtained  over  the  lung.  The  nor- 
mal note  differs  in  intensity  over  the  same  lung,  depending  upon 
the  muscular  thickness  and  the  deposit  of  fat.  It  is  important  to 
accustom  one's  self  to  compare  the  note  obtained  over  analogous 
areas  of  the  two  halves  of  the  body. 

The  Percutory  Determination  of  the  Borders  of 

THE  Lungs  (Fig.  26) 

Upper  border:  the  determination  of  the  upper  borders  of 
the  lungs  is  important ;  because  unilateral  depression  of  the 
1  Percussion  was  discovered  by  Auenbrugger  iu  Graz  (1722-1809). 

K 


130  DISEASES   OF   THE    RESPIRATORY   TRACT       chap 

upper  border  is  frequently  the  first  sign  of  pulmonary  tuber- 
culosis. In  healthy  persons,  the  upper  border  extends  from 
3  to  4  cm.  over  the  upper  border  of  the  clavicle ;  posteriorly 
it  lies  at  the  spinous  process  of  the  7th  vertebra.  In  healthy 
individuals,  both  borders  are  at  the  same  level. 

As  the  limit  of  the  upper  border  is  fixed,  it  may  be  simulta- 
neously determined  if  the  percussion  note  on  one  side  is  less  clear 
than  on  the  other.  Differences  in  sound  at  the  apices,  in  most 
instances  point  to  tuberculosis  (see  below). 


Fig.  26. — Relative  Positions  of  Thoracic  Viscera. 

Lovjer  border:  while  the  determination  of  the  upper  bor- 
ders of  the  lungs  furnishes  data  for  tlie  diagnosis  of  phthisis, 
the  establishment  of  the  lower  border  aids  in  the  diagnosis 


VI  DISEASES   OF   THE    RESPIRATORY   TRACT  131 

of  emphysema  {volumen  pulmonum  auctum).  In  emphysema, 
the  lower  borders  of  the  lungs  are  loiuer  than  in  health. 

The  lower  border  of  the  lungs  lies :  — 

On  the  right  side,  at  the  sternal  border  on  the  6th  rib ;  in 
the  mamillary  line,  at  the  lower  edge  of  the  6th  or  the  upper 
border  of  the  7th  rib ;  in  the  anterior  axillary  line,  at  the 
lower  border  of  the  7th  rib ;  in  the  scapular  line,  at  the  9th 
rib  ;  next  to  the  vertebral  column  at  the  spinous  process  of 
the  11th  dorsal  vertebra. 

On  the  left  side,  the  lower  border  of  the  lung  is  difficult 
to  make  out,  on  account  of  the  proximity  of  the  stomach, 
the  tympanitic  sound  of  which  merges  gradually  into  the 
non-tympanitic  sound  of  the  lung. 

It  is  customary  to  determine  the  lower  border  of  the  lung 
in  the  right  mamillary  line.  In  healthy  persons,  the  relative 
liver  dulness  begins  at  the  lower  border  of  the  4th  rib. 
The  absolute  liver  dulness,  i.e.,  the  lower  border  of  the  lung, 
begins  at  the  lower  border  of  the  6th  or  the  upper  border  of 
the  7th  rib.  If  one  obtains  a  long  clear  note  of  some  dura- 
tion from  the  7th  to  the  9th  ribs,  the  diagnosis  of  emphy- 
sema is  assured. 

Temporary  lowering  of  the  lower  border  of  the  lung  is  found  in 
attacks  of  bronchial  asthma.  The  lower  border  of  the  lung  is 
raised  in  meteorism,  ascites,  abdominal  tumors ;  on  one  side  only, 
indicates  contracting  pleurisy  or  atrophy  of  pulmonary  tissue.  The 
lower  border  of  the  lung  on  the  right  side  is  also  pushed  upward 
in  pleurisy  with  effusion.  This  fact  is  demonstrated,  of  course, 
posteriorly  ;  interiorly  on  the  right  side. 

Resjnratory  changes  in  the  lower  borders.  In  quiet,  normal  breath- 
ing, the  lower  borders  sink  about  1  cm. in  the  mamillary  line;  from 
3  to  4  cm.  in  deep  inspiration.  The  upper  borders,  in  quiet  res- 
piration move  upward  about  J,  in  deep  inspiration  about  1^  cm. 
The  respiratory  displacement  depends  upon  the  position  of  the 
body.  In  the  dorsal  position,  the  anterior  lower  border  of  the 
lung  moves  2  cm.  lower  than  in  the  vertical  position.  The  dis- 
placement in  the  axillary  line  is  most  marked,  and  may  reach  10 
cm.  in  deep  inspiration  with  the  patient  in  the  side  position. 


132  DISEASES   OF   THE    RESPIRATORY   TRACT       chap. 

Respiratory  displacement  is  absent  in  extensive  adhesions 
between  the  pulmonary  and  costal  pleurae,  and  is  much 
diminished  in  emphysema. 

DULNESS    OVER    PULMONARY    ArEAS 

Dulness  over  the  normal  extent  of  the  lungs  may  arise  :  — 

1.  When  the  lung  immediatehj  below  the  chest-wall  is 
devoid  of  air ;  this  area  must  have  an  extent  of  at  least 
4  cm.  Pulmonary  tissue  may  become  deprived  of  air  by 
infiltration  and  by  atelectasis. 

a.  Infiltration  is  due  to  pneumonia,  tuberculosis,  abscess, 
more  rarely  gangrene,  hsemorrhagic  infarct,  ncAV  growths, 
aneurysm. 

h.  Atelectasis  arises  from  compression  (pleuritic  or  peri- 
carditic  exudate  and  new  growths)  or  from  the  resorption 
of  air  when  the  bronchi  become  occluded  (by  tenacious 
secretions  or  tumors  and  by  S3'philitic  stenosis). 

2.  When^/f?i?(Z  is  exuded  into  the  pleura,  between  the  lung 
and  the  chest-wall  (pleuritic  exudate,  hydrothorax) ;  the 
quantity  must  be  at  least  400  c.c.  Dulness  is  evoked, 
also,  by  thickening  of  adherent  layers  of  pleura  (adhesions). 

Dulness  over  the  upper  lobes  (apex)  (with  good  resonance 
behind,  below)  usually  indicates  pulmonary  2:>hthisis,  more 
rarely  pneumonia,  gangrene,  or  yiqw  growths.  Dulness  over 
the  lower  lobes  (posteriorly,  below)  usually  indicates  pneu- 
monia or  pleurisy.  The  differential  diagnosis  is  made  by 
auscultation.  Tubercular  infiltration  of  the  lower  lobes  is 
usually  secondary  to  extensive  tubercular  invasion  of  the 
upper  lobes.  In  rare  cases,  dulness  of  the  lower  lobes  is  to 
be  referred  to  gangrene,  infarct,  or  tumors.  In  bronchitis 
and  miliary  tuberculosis,  there  is  no  dulness  present. 

In  protracted  diseases,  with  the  patient  constantly  in  the  dorsal 
position,  serous  iniiltiations  causing  dulness  may  appear  in  the 
lower  portions  of  both  lungs  {hypostatic  congestion). 


VI  DISEASES   OF   THE    UESPIKATOKY   TRACT  133 

Tympanitic  Resonance  in  the  Area  of  the  Thorax 

Id  the  healthy  thorax,  a  loud  tympanitic  note  is  obtained 
only  over  the  stomach  (semilunar  space,  p.  83j,  and  over  the 
parts  of  the  left  lung  immediately  adjacent  to  it.  These 
parts  are  thin  enough  to  allow  the  tympanitic  note  of  the 
stomach  to  be  evoked  by  percussion. 

The  lower  portion  of  liver  dulness  may  be  concealed  l^y  the  tym- 
panitic note  due  to  tympanites. 

A  tympanitic  percussion  note  in  other  parts  of  the  thorax 
arises  :  — 

1.  In  cavities  in  the  parenchyma  of  the  lung;  the  cavity 
must  have  at  least  the  size  of  a  large  walnut,  must  lie  near 
the  chest-wall  or  must  be  connected  with  it  by  infiltrated 
tissue.  Such  cavities  are  present  in  phthisis,  less  often  in 
bronchiectasis  and  gangrene. 

2.  In  a  collection  of  air  in  the  pleural  sac  (pnemno- 
thorax),  but  only  while  the  air  is  not  under  too  great  tension. 
Otherwise  the  note  is  deep  and  loud,  but  not  tympanitic. 

3.  In  complete  infiltration  of  large  pulmonary  areas,  by 
which  there  is  a  good  conduction  of  sound  between  the 
broncho-tracheal  column  of  air  and  the  chest-wall ;  for 
instance,  in  tubercular  infiltration  of  an  entire  upper  lobe, 
and  in  the  second  stage  of  pneumonia  (dulness  with  tym- 
panitic sound). 

4.  In  diminished  tension  (relaxation,  atony)  of  the  pul- 
monary tissue :  over  pleuritic  and  pericarditic  exudate  and 
pneumonic  infiltration ;  frequently  in  the  first  and  third 
stages  of  croupous  pneumonia  and  in  oedema  of  the  lungs. 

All  conditions  in  which  a  tympanitic  note  is  heard  have  this 
in  common  :  that  a  column  of  air  above  is  brought  into  vibration 
(without  vibration  of  the  tissues  of  the  lung). 

In  the  cases  of  cavities  and  pneumothorax,  the  column  of  air 
in  the  space  is  percussed  directly;  in  the  instances  of  extensive 
infiltrations,  one  percusses  the  normal  cavities  (broncho-tracheal 


134  DISEASES   OF   THE    RESPIRATORY   TRACT       chap. 

column  of  air)  through  the  thickened  tissues.  Puhiionary  tissue 
lying  above  exudates  is  robbed  of  its  elasticity  and  vibratory 
power,  and  hence,  in  percussion,  the  air  only  contained  in  the 
lung  vibrates. 

A  metallic  (amphoric  note)  differs  from  a  tympanitic  note 
by  its  higher  pitch  and  by  its  longer  duration.  In  addition  to 
the  fundamental  note,  there  are  overtones  to  be  heard,  which 
slowly  disai)pear.    They  may  be  compared  to  a  metallic  echo. 

Amphoric  resonance  may  be  elicited  over  the  thorax  :  — 

1.  In  the  presence  of  cavities  with  homogeneous  walls, 
which  must  have  the  size  of  a  man's  fist  at  least  (6  cm. 
diameter). 

2.  In  pneumothorax,  when  the  air  present  is  under  a 
certain  pressure,  not  too  great. 

In  order  to  appreciate  amphoric  resonance  more  distinctly, 
percussion  by  means  of  the  hammer  and  pleximeter  may  be 
employed  {mediate  percussion).  While  performing  auscul- 
tation over  the  cavity,  the  pleximeter,  placed  next  to  the 
stethoscope,  is  lightly  hit  by  the  hammer.  By  this  means 
a  clear,  metallic  note  is  elicited. 

The  cracked-pot  sound  (bruit  de  pot  file)  is  brought  out  by 
a  short,  sharp  percussion.  It  is  best  obtained  with  the 
patient's  mouth  open,  over  a  superficial  caviti/  which  com- 
municates with  a  bronchus  by  a  narrow  opening.  The 
sound  may  resemble  that  of  the  rattling  of  coins.  Caution 
must  be  observed  in  estimating  the  value  of  the  cracked- 
pot  sound,  as  it  may  appear  in  healthy  persons,  especially 
children,  in  speaking  and  singing;  and  moreover,  is  some- 
times found  in  tissues  relaxed  and  infiltrated  (pleurisy  and 
pneumonia). 

Changes  of  Sound  and  Symptoms  of  Cavities 

A  tympanitic  note  is  high  or  loiv  according  to  the  lengtli 
of  the  column  of  air  which  produces  it,  and  the  breadth  of 
the  opening  by  which  it  reaches  the  external  air.      The 


VI  DISEASES   OF   TUE   RESPIRATORY   TRACT  135 

shorter  the  column  of  air  and  the  wider  the  opening,  the 
higher  the  note.  By  having  a  patient  open  his  niouiii, 
the  ojjening,  communicating  with  a  cavity  which  is  freely 
connected  with  a  large  bronchus,  may  be  enlarged;  by 
changing  the  position  of  a  patient,  the  diameters  of  a  jjuru- 
lent  cavity,  with  unequal  diameters,  may  be  changed.  By 
tlms  changing  the  physical  conditions,  high  and  deep  notes 
may  l)e  artificially  produced.  This  is  known  as  sound 
mutation  or  change. 

1.  The  change  of  sound  known  as  Wintrich's  consists  of  the 
change  produced  in  a  tympanitic  note  by  the  opening  and  closing 
of  the  mouth  —  higher  in  the  former,  lower  in  the  latter  case.  Found 
in  lung  cavities  and  pneumothorax  ivhen  these  communicate  freely  with 
a  bronchus.     Rarely  in  pneumonia  and  over  pleuiitic  exudates. 

One  can  imitate  this  phenomenon  by  percussing  the  larynx  with 
alternate  opening  and  closing  of  the  mouth. 

An  interrupted  Wintrich's  sound  change  is  the  designation  given 
to  the  disappearance  of  the  phenomenon  when  the  patient  sits  up, 
while  it  was  easily  obtained  when  he  was  lying  down,  and  vice 
versa.  It  is  caused  by  the  occlusion  of  the  bronchus,  which  in  a 
certain  position  of  the  body  freely  opens  into  the  cavity. 

2.  Gerhardt' s  change  of  sound:  when  the  patient  sits  up,  the 
tympanitic  note  is  deeper  than  when  he  is  lying.  This  j)henom- 
enon  appears  in  oval  cavities  which  are,  in  part,  filled  with  fluid ; 
the  note  has  the  lowest  pitch  when  the  longest  diameter  is  hori- 
zontal. When  this  diameter  is  diminished  by  change  of  position, 
the  note  becomes  clearer.  (If  the  note  becomes  higher  when  the 
patient  sits  up,  the  diagnosis  of  a  cavity  is  not  certain.)  This 
phenomenon  may  be  produced  by  percussing  a  partly  filled  bottle. 

8.  Respiratory  change  of  sound :  in  very  deep  inspirations,  the 
tympanitic  note  over  cavities  sometimes  rises  in  pitch,  probably 
by  the  increased  width  of  the  glottis,  which  represents  an  increase 
in  the  size  of  the  cavity. 

4.  Biermer's  change  of  sound :  percussion  over  a  pne\imothorax 
containing  fluid,  the  percussion  note  is  deeper  in  the  recumbent 
than  in  the  sitting  posture,  because  the  long  diameter  of  the  air- 
containing  pleura  becomes  increased,  in  the  lying  position,  at  the 
expense  of  the  long  diameter  of  the  exudate,  which  sinks  from 
the  diaphragm  upon  the  posterior  chest-wall. 


136  DISEASES   OF   THE    RESPIRATORY   TRACT       chap. 

Auscultation  of  the  Thorax^ 

By  means  of  auscultation  one  appreciates  :  (1)  the  respir- 
atory murmur ;  (2)  rales  and  friction  sounds. 

The  Respikatory  Murmur 

Vesicular,  bronchial,  amphoric,  and  broncho-vesicular  breath- 
ings are  distinguished. 

Vesicular  breathing  {ceU-breathing)  is  found  over  the  entire 
healthy  lung.  It  is  principally  audible  on  inspiration ;  of 
a  shuffling  character,  and  is  not  heard  on  expiration,  or  if 
heard,  is  short  and  uncertain,  and  is  rarely  audible  as  a 
vesicular  murmur. 

Vesicular  breathing  may  be  easily  imitated  by  placing  the  lips 
and  teeth  as  though  one  were  to  pronounce  a  soft  /  and  then 
taking  a  deep  inspiration.  Vesicular  respiration  arises  in  the 
trachea  and  the  large  bronchi,  and  is  therefore  really  bronchial 
breathing,  which  attains  its  peculiar  shuffling  character  through 
being  conducted  into  the  small  bronchi  and  the  alveoli  of  the  lung. 

Clear,  soft  vesicular  breathing  without  rales  is  a  positive 
sign  that  the  auscultated  area  of  lung  is  healthy. 

Diminished  intensity  of  vesicular  respiration  is  found  in 
emphysema,  since,  in  consequence  of  the  distention  of  the 
lung  tissues,  only  a  small  quantity  of  air  enters  the  alveoli ; 
in  pleurisy,  because  the  fluid  between  the  chest-wall  and 
the  lung  is  a  poor  conductor  of  sound;  in  instances  of 
adherent  and  thickened  pleurae,  because  the  lung  enveloped 
by  them  can  not  unfold  itself.  Over  very  large  pleuritic 
exudation,  the  respiratory  murmur  is  entirely  absent. 

An  increased  intensity  of  vesicular  breathing  is  normal  in 
children :  puerile  respiration.  It  appears  in  swelling  and 
stenosis  of  the  bronchi  and  in  l)ronchitis  (because  the 
current  of  air  is  inspired  with  greater  force  to  overcome 
the  obstructions  present). 

1  Auscultation  was  discovered  by  the  Parisian  clinician  Laennee  (1781- 
182G). 


VI 


DISEASES   OF   THE   RESPIRATORY   TRACT  137 


An  increased  intensity  of  vesicular  expiratioyi  and  a  pro- 
longation of  it  arises  when  there  are  obstructions  to  the  exit 
of  air  from  the  alveoli  because  of  narrowing  of  the  smaller 
bronchi,  as  in  bronchitis  and  bronchial  asthma.  Prolonged 
expiration  increased  in  intensity  over  the  apex  of  the  lung 
is  an  early  sign  of  phthisis. 

Interrupted  or  jerkij  re.^nrntion  is  vesicular  breathing  in  which 
inspiration  is  accomplished  with  several  intermissions.  It  may 
appear  in  healthy  persons  who  breathe  slowly  and  irregularly;  but 
it  is  often  found  at  the  apex  as  an  early  sign  of  tuberculosis.  It 
must  not  be  given  too  high  a  value,  and  is  to  be  considered  only 
in  connection  with  other  symptoms. 

Systolic  vesicular  breathing  refers  to  the  increased  respiratory 
murmur  often  heard  in  the  neighborhood  of  the  heart  during  its 
systole.     It  has  no  diagnostic  significance. 

Bronchial    breathing   {cavernous   respiration)  is    found    in 

health  over  the  larynx,  the  trachea,  and  the  inter-scapular 

space.     It  is  of  a  puffing  character,  principally  audible  on 

expiration;   on  inspiration  it  is  usually  heard  shorter  and 

weaker. 

Bronchial  breathing  may  be  imitated  by  putting  the  mouth  in 
the  position  of  pronouncing  the  soft  German  cli  and  slowly  ex- 
piring. Bronchial  breathing  arises  through  the  rotatory  motion 
imparted  to  the  inspired  air  as  it  passes  through  the  rima  glottidis, 
which  is  in  turn  continued  in  the  broncho-tracheal  column  of  air. 

Bronchial  breathing  is  produced  by  analogous  conditions 
to  those  which  call  forth  a  tympanitic  percutory  note :  — 

1.  In  large  cavities,  but  the  conducting  bronchus  must 
be  free. 

2.  When  the  lung  is  so  consolidated  that  the  bronchial 
respiratory  murmurs  of  the  large  bronchi  are  conducted 
unchanged  to  the  chest-wall : 

(a)  in  infiltration  by  pneumonia  or  tuberculosis,  less  often, 

gangrene; 
(h)  in  compression,  particularly  above  exudates  into  the 

pleura. 


138  DISEASES   OF   THE    RESPIRATORY  TRACT        chap. 

Dulness  and  bronchial  breathing  over  the  lower  lobe,  with 
an  nninvolved  upper  lobe,  usually  denotes  pneumonic  in- 
hltration.  Dulness  and  bronchial  breathing  over  the  apex, 
with  a  normal  lower  lobe,  usually  indicates  tubercular  in- 
filtration. But  it  must  not  be  forgotten  that  these  symp- 
toms may  point  to  an  upper-lobe  pneumonia,  a  lower-lobe 
tuberculosis,  gangrenous  infiltration,  pleuritic  thickening,  or 
compression  due  to  tumors  or  aneurysms. 

A  loud,  tympanitic  note  and  bronchial  breathing  denote 
a  cavity ;  a  loud  deep  note  with  no  respiratory  murmur,  a 
closed  pneumothorax ;  dulness  with  no  respiratory  murmur, 
a  pleuritic  effusion. 

Metamorphic  respiration  is  the  name  given  to  an  uncommon  re- 
spiratory murmur  which  begins  as  vesicular  and  becomes  bronchial. 
It  is  heard,  when  at  all,  over  cavities,  but  is  not  at  all  characteristic. 

Amphoric  respiration  is  never  heard  over  the  healthy  chest; 
it  is  a  whistling  respiratory  sound  with  a  metallic  echo,  pro- 
duced under  the  same  conditions  as  the  metallic  percussion 
note.  It  is  pathognomoidc  for  cavities  with  walls  of  uniform 
density  of  a  diameter  of  at  least  6  cm.,  and  for  an  ope?i 
pneumotliorax.  Over  a  closed  pneumothorax  no  respiratory 
murmur  is  heard. 

Amphoric  respiration  may  be  imitated  by  blowing  over  the  top 
of  a  large  bottle. 

Broncho-vesicular  breathing  is  breathing  which  is  neither 
distinctly  bronchial  nor  distinctly  vesicular.  One  should 
be  very  cautious  in  diagnosticating  this  variety  of  respira- 
tory murmur,  and  should  try,  by  careful  auscultation,  and 
by  having  the  patient  take  deep  inspirations,  to  give  the 
murmur  a  vesicidar  or  a  bronchial  character. 

Broncho- vesicular  respiration  is  found  in  healthy  per- 
sons, on  superficial  breathing,  in  the  supra-  and  infra-spinous 
regions.  In  pathological  conditions  it  is  fre(|uently  heard 
without  allowing  any  diagnostic  conclusion  to  be  drawn  from 


VI  DISEASES   OF  THE   RESPIRATORY   TRACT  189 

it.  When  broncho-vesicular  breathing  is  permanently  heard 
at  one  apex,  it  may  be  regarded  as  a  sign  of  beginning  tuber- 
culosis. 

Rales  axd  Frictiox  Souxds 

The  adventitious  respiratory  sounds  are  ahvays  signs  of 
a  diseased  condition  of  the  mucous  membrane  of  the  lung, 
or  of  a  collection  of  secretions,  or  of  pus.  Rales  are  known 
as  tJry  and  moist. 

Dry  rdles  are  caused  by  the  passage  of  the  inspired  air 
through  a  narrovred  bronchus  or  one  covered  with  a  tena- 
cious secretion.  They  inay  be  of  a  inirring  or  sonorous 
(rhojicM  sonori),  or  of  a  ichistUng  or  sibilant  {rlionclii  sibilan- 
tes)  character.     They  are  pathognomonic  for  bronchitis. 

Moist  rdles  are  heard  when  there  is  a  collection  of  secre- 
tions which  conduct  the  inspired  air,  or  when  bubbles  con- 
taining air  are  ruptured,  or  when  closed  alveoli  or  bronchi- 
oles are  forced  open. 

Moist  rales  may  be  plentiful  or  scattered,  fine  or  coarse; 
they  may  be  ringing  or  not,  metallic  or  not. 

The  coarseness  of  rales  depends  upon  the  size  of  the 
cavity  in  which  they  arise ;  fine  rales  are  usually  derived 
from  the  small  bronchi  in  a  beginning  infiltration;  coarse 
rales  in  large  bronchi  and  cavities. 

Crepitant  rales  (biülous  rales)  take  their  origin  in  the  forc- 
ing open  of  previously  closed  alveoli,  and  are  a  subdivision 
of  fine  rales.  They  may  be  imitated  by  rubbing  the  hair 
between  the  fingers.  Crepitant  rales  are  heard  in  the  1st 
and  3d  stages  of  pneumonia,  in  oedema  of  the  lungs,  in  miliary 
tuberculosis ;  sometimes,  in  the  apices  and  the  areas  of  lung 
immediately  beneath  them,  in  kecdthy  organs  during  the  first 
few  inspirations  after  partial  atelectasis. 

Binging  rales  are  often  heard  under  the  same  conditions 
as  bronchial  breathing  (in  cavities,  in  large  infiltrations 
which  act  as  sound  conductors,  in  compression). 


140  DISEASES   OF   THE    RESPIRATORY   TRACT        chap. 

Metallic,  ringing  rales  are  often  heard  in  connection  with 
a  metallic  percussion  note  and  amphoric  breathing. 

A  single  metallic  rale  is  known  as  tinkling  (tintement  metalllque, 
the  sound  of  falling  drops  of  water).     Heard  in  pneumothorax. 

Succussion  (succussio  Hiijpocratis)  is  a  metallic  splashing 
heard  at  some  distance  from  a  patient  when  the  upper  part 
of  his  body  is  energetically  shaken  from  side  to  side.  It 
is  pathognomonic  for  the  simultaneous  presence  of  air  and 
fluid  in  the  pleural  sac  (sero-  or  pyo-pneumothorax). 

Succussion  may  also  be  heard  over  a  large  stomach  after  the  in- 
gestion of  fluids.  It  speaks  in  this  instance  in  favor  of  gastric 
dilatation,  but  does  not  prove  it. 

Friction  sounds  (pleuritic)  are  heard  when  two  adjacent 
layers  of  pleura,  rubbing  against  each  other  in  the  respira- 
tory act,  become  roughened  by  deposits  of  fibrin.  They  are 
pathognomonic  for  pleurisy,  are  most  frequent  in  dry  pleu- 
risy, and  in  large  effusions  are  heard  usually  in  the  stage  of 
resorption.  Friction  sounds  are  absent  in  effusions  with 
stasis  (hydrothorax)  and  when  adhesions  between  the  layers 
of  the  pleura  exist. 

The  distinction  between  friction  sounds  and  dry  rales  is  some- 
times difficult  to  make.  It  may  be  remarked  that  rales  are  changed 
by  coughing,  friction  sounds  are  not;  that  friction  sounds  are  in- 
creased in  intensity  by  the  pressure  of  the  stethoscope,  and  that 
under  these  circumstances  a  complaint  of  pain  is  made ;  that 
friction  sounds  are  appreciable  to  the  hand. 

They  may  be  compared  to  the  creaking  of  new  soles  and  to  the 
rustling  of  a  tense  sail. 

Pectoral  Fremitus 

Pectoral  or  vocal  fremitus  is  appreciated  by  placing  the 
hands  symmetrically  on  the  two  sides  of  the  chest  while  the 
patient  speaks  or  counts  in  a  deep  voice.  In  healthy  persons 
one  feels  a  distinct  vibration  of  the  chest-wall  produced  by 
the  conduction  of  the  voice. 


VI  DISEASES   OF   THE   RESPIRATORY   TRACT  141 

Pectoral  fremitus  is  increased  in  pneumonia,  above  pleu- 
ritic effusions,  in  cavities  with  thickened  walls.  (Infiltrated 
and  compressed  tissues  are  good  conductors  of  sound ;  in 
cavities  the  sound  of  the  voice  is  intensified  by  reflection 
from  the  walls.) 

Vocal  fremitus  is  diminished  or  absent :  — 

a.  When  the  pleural  sac  is  filled  with  fluid  or  with  air 
{pleurisy  and  pneumothorax).  Over  pleural  adhe- 
sions, vocal  fremitus  is  frequently  well  preserved. 

h.  When  the  large  bronchi  are  occluded  by  tumors  or 
stenosis. 

The  diminished  intensity  or  absence  of  vocal  fremitus 
is  of  diagnostic  value  only  when  the  voice  is  strong  and 
deep.  A  weak  voice  produces  a  weak  fremitus.  In  very 
stout  people,  it  can  not  be  well  felt. 

Auscultation  of  the  voice.  The  auscultation  of  a  healthy  chest 
during  talking  gives  only  an  indistinct  humming.  This  is  diuiin- 
ished  under  the  same  conditions  as  vocal  fremitus.  The  voice 
seems  to  be  intensified  when  the  waves  of  sound  travel  through 
good  conductors,  that  is,  through  infiltrated  or  compressed  tissues, 
or  through  cavities  with  thickened  walls.  Vocal  auscultation  is 
therefore  bounded  by  the  same  limitations  as  vocal  fremitus  and 
bronchial  respiration.  An  increased  auscultatory  hitensity  of  the 
voice  is  called  bronchophony ;  very  much  heightened  intensity,  pec- 
toriloquy. 

JEgophony  is  the  name  given  to  a  peculiar  sound  of  the  voice, 
possessing  a  tremor  and  sounding  like  the  bleating  of  a  goat,  which 
is  often  heard  at  the  upper  limit  of  an  extensive  pleuritic  effusion. 

Examination  of  the  Sputum 

The  examination  of  expectorated  material  coughed  up 
is  indispensable  for  the  diagnosis  of  diseases  of  the  lungs. 
The  examination  begins  with  a  simple  insj)ection  of  the 
sputum  (macroscopic  examination)  which  is  followed  in  case 
of  necessity  by  a  microscopic  examination. 


142  DISEASES   OF   THE    RESPIRATORY   TRACT        chap. 

Every  sputum  may  be  placed  in  a  group  according  to  its 
main  constituents:  mucous,  purulent,  serous, ßhrinous,  bloody 
sputum ;  or  it  may  represent  a  mixed  form,  as  muco-puru- 
lent,  bloody-serous,  etc. 

1.  P7cre  raucous  sputum  (tenacious,  glossy,  sticking  to  the 
bottom  of  the  glass)  is  characteristic  of  a  beginning  bron- 
chitis. As  bronchitis  may  be  the  forerunner  of  tuberculosis, 
a  sputum  consisting  of  pure  mucus  must  be  given  cautious 
diagnostic  judgment.  The  expectoration  of  the  nose  and 
pharynx  is  often  purely  mucous. 

2.  Pure  2'>nrulent  sputum  (thick,  confluent  pus,  not  foamy) 
is  found  almost  solely  in  perforation  of  purulent  foci :  empy- 
ema, abscess  of  the  lungs  or  of  the  neighboring  organs  ;  also 
in  bronchorrhoea. 

3.  Muco-purulent  sputum  is  found  most  frequently,  and 
has  no  characteristic  points  for  differential  diagnosis.  Is 
seen  in  severe  bronchitis  as  well  as  in  phthisis  pulmonum. 
In  bronchitis  pus  and  mucus  are  often  intimately  mixed ;  in 
phthisis  it  frequently  consists  of  single  balls  which  have  a 
gnawed  appearance,  are  surrounded  by  mucus,  and  sink  to 
the  bottom.  This  kind  of  sputum  (nummulous,  globosum  et 
fiüuhun  petens)  is  mostly  characteristic  of  tubercular  cavi- 
ties, but  occasionally  appears  in  bronchorrhoea. 

Profuse  muco-puruleiit  sputum  often  forms  three  layers  on  stand- 
ing :  the  lowest,  pus,  then  serous  fluid,  on  top  foamy  nuicus.  Found 
most  often  in  bronchiectasis  and  cavities,  but  is  not  pathogno- 
monic. 

4.  Serous  sputum,  thin,  fluid,  usually  stained  a  light  red, 
is  pathognomonic  for  oedema  of  the  lungs  ;  its  appearance  is 
usually  a  bad  prognostic  sign,  usually  a  sign  of  early  death 
(stertor). 

5.  Pure  bloody  sputum  ^haemoptysis)  is  expectorated  when 
through  some  ulcerative  process  a  pulmonary  blood-vessel 
becomes  eroded,  or  when  in  the  pulmonary  circulation  or  in 
isolated  areas  (embolism),  stasis  of  high  degree  is  present. 


VI  DISEASES   OF   THE    RESPIRATORY   TRACT  143 

Differential    diagnosis    as   to   haematemesis    (p.    79).      Hae- 
moptysis appears :  — 

a.  Principally  in  tubercular  phthisis  ;  sometimes  in  the  first 
stage  (initial  haemoptysis)  or  in  any  stage  of  the 
snbseqnent  course  of  the  disease  ;  the  amount  of  the 
coughed-up  blood  varies  from  1  to  2  teaspoons  to 
i  litre  or  more.  The  proof  of  the  presence  of  other 
signs  of  tuberculosis  is  required  to  make  a  positive 
diagnosis. 

h.   Less  often  in  abscess  of  the  lung  or  gangrene. 

c.  In  extensive  stasis  in  the  pulmonary  circulation,  espe- 

cially in  mitral  lesions. 

d.  In  haemorrhagic  infarcts  of  the  lung ;  the  source  of  the 

embolus  must  be  proA^en  (venous  thrombosis,  tlii'om- 
bosis  in  the  right  ventricle)  ;  when  possible,  the  area 
of  dulness  of  the  infarct,  or  rales,  must  be  elicited. 

e.  In  aneurysm  of  the  aorta  which  may  lead  to  profuse, 

often  fatal,  pulmonary  haemorrhage. 
/.    In  very  rare  instances,  when  a  dilated  vein  (varix)  of 
one   of   the   large   bronchi   bursts  in  an  otherwise 
healthy  person.      This  diagnosis  is  justified  only 
when  the  other  causes  are  excluded. 

An  haemoptysis  which  appears  at  the  time  of '  suppressed  menses 
in  a  young  girl  may  be  regarded  as  beneficial  (vicarious  haemopty- 
sis). One  must  not  neglect  the  examination  for  tuberculosis,  how- 
ever. 

6.  Bloody-mucous  spiäum  (like  raspberry  jelly)  is  occasion- 
ally seen  in  carcinoma  of  the  lung ;  when  it  is  more  bloody 
than  mucous,  sometimes  stained  j^ellowish-brown,  in  the  first 
stage  of  pneumonia  and  in  haemorrhagic  infarcts. 

Saliva  stained  with  blood  is  often  expectorated  by  hysterical 
patients,  and  may  lead  to  error. 

Fibrin  in  quite  large  quantities  is  seen  in  fibrinous  bron- 
chitis and  pneumonia ;   if  one  shakes  up  the  sputum  with 


144  DISEASES   OF   THE   RESPIRATORY   TRACT       chap. 

water  in  a  test-tube,  branches  of  tibrin  like  those  of  a  tree 
appear  {bronchial  casts). 

In  order  to  decide  whether  sputum  contains  fibrin,  Ehrliches 
three-color  mixture  may  be  employed.  This  tri-acid  mixture  con- 
tains acid  fuchsin,  methyl-green,  orange-G.  The  acid  fuchsin  is 
absorbed  by  the  pure  albumin  present,  while  nuclein  (the  albu- 
min of  the  nucleus)  and  mucin  are  stained  with  the  basic  methyl- 
green.  If  a  specimen  of  sputum  is  shaken  up  with  this  mixture, 
pneumonic  expectoration  will  be  stained  red  because  of  the  fibrin 
it  contains,  the  sputum  of  bronchitis  will  be  a  bluish-green  because 
of  the  mucus  and  leucocytes  it  holds.  This  test  may  be  employed 
microscopically  on  dry  specimens. 

The  smell  and  color  of  the  sputum  are  next  to  be  observed. 
Most  sputa  have  an  insipid,  sweetish  smell.  A  mouldy  odor 
may  accompany  material  arising  from  the  mouth,  the  teeth, 
the  nose,  and  the  pharynx.  A  sickly,  foul  odor  is  a  sign  of 
purulent  bronchitis  or  gangrene  of  the  lung  or  ruptured 
putrid  abscesses  (see  below). 

A  foul  odor  may  come  from  the  oesophagus  or  nose,  which  must 
always  be  carefully  examined  as  possible  sources  of  putrid  sputum. 

The  color  is  usually  a  yellowish-green.  Sputa  of  other 
colors  have  important  bearings  :  red  color  (see  bloody  sputa)- 

Rubiginous  (rusty)  sputum,  pathognomonic  for  pneumonia. 

Ochre-yellow  sputum,  pathognomonic  for  the  perforation  of 
foci  of  liver  disease  (echinococci,  abscesses  from  biliary  cal- 
culi, necrotic  liver  tissue).  The  color  comes  from  the  large 
quantity  of  bilirubin. 

A  similar  color  is  caused  by  the  activity  of  bacteria :  sputum  of 
the  color  of  the  yolk  of  an  egg.  The  color  becomes  more  intense 
when  exposed  to  the  air,  and  if  a  small  part  of  the  sputum  is  trans- 
ferred to  clear  sputum,  the  latter  assumes  the  yellow  color  in  a  short 
time. 

Grass-green  sputum,  characteristic  of  a  slow  resolution  of 
a  pneumonia,  usually  indicates  a  transition  to  tuberculosis ; 
also  seen  in  pneumonia  accompanied  l)y  icterus. 


VI  DISEASES   OF   THE    RESPIRATORY   TRACT  145 

The  green  color  may  also  be  caused  by  bacterial  life.  This  form 
may  be  recognized  by  its  imparting  its  color  to  clear  sputum. 

The  differently  colored  sputa  which  acquire  their  color 
from  external  sources  are  without  diagnostic  significance : 
him  sputa  in  workmen  in  chemical  factories,  red  and  yellovj 
in  workers  at  the  forge,  black  in  workers  in  coal. 

Lastly,  the  amount  of  sputum  in  24  hours  must  be  noted. 
For  diagnostic  purposes  it  may  be  important  when  there 
is  a  very  great  quantity  of  secretion  (purulent  bronchitis, 
bronchiectasis,  tuberculous  cavities,  perforating  empyema, 
etc.).  In  many  cases  the  intensity  of  the  pathological  pro- 
cess may  be  estimated  by  the  amount  of  sputum. 

Microscopic  Examination 

A  microscopic  examination  of  the  sputum  must  be  made 
in  all  cases  in  which  the  examination  of  the  thorax  and  the 
inspection  of  the  sputum  have  not  led  to  a  positive  diag- 
nosis (for  example,  when  there  is  a  suspicion  of  tuberculosis, 
in  the  presence  of  blood-stained,  mucous  sputum  and  ill- 
smelling  sputum,  etc.). 

Important  elements  are :  elastic  fibres,  fragments  of  lung 
tissue,  tubercle  bacilli,  heart-disease  cells,^  eosinophile  cells, 
Leyden's  asthma  crystals,  and  Curschmann's  spirals.  These 
are  some  elements  which  help  to  secure  the  diagnosis  made : 
crystals  of  the  fatty  acids,  h^matoidin  crystals,  bronchial 
casts,  etc. 

Elements  which  lack  particular  diagnostic  importance  (ire  (Fig.  27)  : 

White  Uood-cells,  present  in  large  quantity  in  eveiy  sputum, 
often  degenerated,  often  fatty. 

Pavement  epithelium  comes  from  the  mouth  and  the  true  vocal 
cords. 

Cylindrical  epithelium  is  not  often  found ;  it  conies  from  the  nose, 
the  upper  pharynx,  the  lower  part  of  the  larynx,  and  the  bronchi. 

1  We  have  translated  the  word  "  Herzfehlerzeil  en  "  as  above.— The 
Translators. 


146 


DISEASES   OF   THE    RESPIRATORY   TRACT        chap. 


The  heart-disease-cells  are  large,  ovoid  or  round,  with  a  nucleus 
which  resembles  a  bubble,  and  are  usually  filled  with  particles  of 
coal,  as  well  as  fat  and  myelin  (anthracosis).  Although  the  pres- 
ence of  aveolar  epithelium  is  not  characteristic  of  tuberculosis,  the 
presence  of  a  large  quantity  of  anthracotic  cells  must  awaken  a 
suspicion  of  the  disease. 

IsoJ^ated  red  blood-cells  are  without  significance.  They  are 
present  in  abundance  in  bloody  sputum. 

Red  blood-cells. 


Fatty  detritus.     - 


Epithelium  from 
the  mouth. 


Alveolar  epi- 
thelium. 


.al  epithelium 


Leucocytes. 


Fio.  27.-  Morning  Spütfm  in  Chronic  Bronchitis,  containing  No 
Pathological  Elements. 


Sarcina  ptdmonum  is  seen  now  and  then.  Tt  has  no  diagnostic 
importance. 

'J'lie  ordinary  bacteria  are  present  in  profusion  in  every  sputum, 
particularly  in  old  sputum,  and  have  no  diagnostic  value.  Leplo- 
thrix  (stained  blue  with  Lugol's  solution)  are  present  in  gangrene ; 
they  also  appear  in  the  follicles  of  the  tonsils  in  the  healthy. 
Lugol's  solution  contains  iodine,  1;  iodide  of  potassium,  2;  dis- 
tilled water.  100  i)arts. 


VI  DISEASES   OF  THE    RESPIRATORY  TRACT  147 

Characteristic  Elements 

Elastic  fibres,  in  all  destructive  processes :  tuberculosis, 
abscess,  gangrene.  In  gangrene  not  so  many  fibres  are 
found,  for  there  is  a  ferment  in  the  sputum  which  dissolves 
them.  Abscess  is  rare  and  is  to  be  diagnosticated  from 
other  symptoms  (see  below),  so  that,  as  a  rule,  the  presence 
of  elastic  fibres  speaks  in  favor  of  tuberculosis. 

To  find  elastic  fibres,  a  cheesy  particle  may  be  selected  from 
the  sputum  with  a  curved  forceps.  The  sputum  should  be  poured 
on  a  black  plate  to  render  the  selection  easier.  Low  powers  of  the 
microscope  will  answer  for  the  preliminary  examination.  The 
sputum  may  be  previously  boiled  in  a  test-tube  with  an  equal 
quantity  of  a  10  per  cent,  potassium  hydrate  solution  and  allowed 
to  precipitate.     The  sediment  is  then  examined  microscopically. 

Fragments  of  lung  tissue  appear  as  small  black  particles, 
visible  to  the  naked  eye,  in  abscess  and  gangrene.  In  foul- 
smelling  sputum  their  presence  speaks  in  favor  of  gangrene 
rather  than  fetid  bronchitis. 

Heart-disease-cells  are  found  in  the  sputum  in  all  diseases 
in  which  there  is  chronic  pulmonary  congestion,  as  in  mitral 
disease  and  in  all  cases  of  dilatation  of  the  left  ventricle. 
These  conditions  frequently  superinduce  cardiac  asthma 
and  secondary  emphysema.  The  heart-disease-cells  are  des- 
quamated alveolar  epithelium  containing  granular^  brownish- 
yellow  pigment. 

The  source  of  this  pigment  is  undoubtedly  the  blood,  and  may 
be  proven  by  the  hsemosiderin  reaction :  to  a  fresh  sf)ecinien 
diluted  hydrochloric  acid  and  the  yellow  potassium  ferrocyanide 
(5  per  cent,  solution)  are  added.  The  pigment  granules  take  on 
a  blue  color  from  the  iron  they  contain. 

Eosinophile  cells  appear  in  the  sputum  usually  in  combi- 
nation with  Leyden's  asthma  crystals.  They  are  large  cells 
Avith  very  fine,  colorless  granulations  which  stain  a  beauti- 
ful red  with  eosin.     Their  presence  in  abundance  seems  to 


148 


DISEASES   OF   THE   RESPIRATORY   TRACT        chap. 


bear  some  relation  to  attacks  of  asthma ;  but  nothing  deti- 
nite  can  be  said  as  to  their  significance. 

The  staining  of  these  cells  in  dry  specimens  may  be  best  accom- 
plished by  the  following  solution  (Dr.  Bein)  :  concentrated  aqueous 

solution  of  methylene 


blue  50 ;  absolute  alco- 
hol and  distilled  water, 
of  each  24.  To  this 
solution  is  added  a 
piece  of  eosin  the  size 
of  a  bean.  In  this  so- 
lution leucocytes  and 
bacteria  are  stained 
blue ;  the  eosinophile 
granulations,  red. 

Leyden^s  asthma 
crystals  (Fig.  28), 
strongly  refractive, 
octahedral  figures, 
are  found  almost 
solely  in  bronchial 
asthma.  Macroscop- 
sausage-shaped    particles. 


Fig.  2S. — Asthma  Crystals. 


ically,   they    appear   in    yellow 

Chemically,  they  consist  of  diethylendiamin. 

Gurschmann^s  spirals  (Fig.  29),  also  found  in  the  sputum 
of  asthma  but  seen  much  less  frequently,  may  be  recog- 
nized with  the  naked  eye,  better  with  a  magnifying  glass,  as. 
fine  thread-like  bodies,  often  contained  in  sago-like  particles 
of  mucus.  They  are  conglomerations  of  mucus  wound  in 
the  manner  of  a  corkscrew,  with  a  light  central  line. 

Fibrin  may  often  l)e  appreciated  macroscopically.  Shaken  with 
water,  it  may  be  recognized  by  its  forming  bronchial  casts  shaped 
like  the  branches  of  a  tree.  Microscopically,  it  is  known  by  its 
brightness,  its  fine  streaking,  and  its  homogeneity  (staining  reac- 
tion, p.  144).  Fibrin  is  found  in  asthma,  fibrinous  bronchitis,  and 
pneumonia. 

Crystals  of  the  fdlty  acids  usually  present  themselves  as  curved, 


VI 


DISEASES    OF   THE    RESPIRATORY   TRACT 


149 


colorless  needles,  frequently  in  bunches;  are  easily  distinguishable 
from  tyrosin  and  other  crystals  by  melting  when  warmed.  Are 
present  in  gangrene  and  fetid  bronchitis,  usually  contained  in 
yellow,  ill-smelling  plugs  the  size  of  a  pin  head  (Dittrich's  plugs). 


Fig.  29.  —  Curschmann's  Sptkals. 
a:  magnified  80  times,     b  :  a  piece  of  a,  magnified  300  times. 

Hoematoidin  crystals  are  found  in  old  haemorrhages,  especially  in 
abscess  and  perforating  lesions  of  the  liver  (ochre-j^ellow  sputum). 
They  occur  in  brownish-yellow  groups,  as  isolated  needles,  rhombi, 
and  flakes. 

Cholesterin  crystals  are  six-angled,  notched  plates  seldom  found 
in  old,  purulent  sputum  (abscess  and  cavities) . 


150  DISEASES   OF   TUE    RESPIRATORY   TRACT        chap. 

Ti/rosin  crystals  are  bunches  of  needles,  in  old  pus,  particularly 
in  the  drying  pus  of  perforating  emp3'ema. 

Small  cysls  of  echinococcus  or  its  hooks  are  rarely  present  in  the 
sputum,  and  when  they  are,  denote  echinococcus  of  the  lung  or 
perforation  from  some  neighboring  organ  (see  Chap  XII.). 

The  cocci  of  pneumonia  (see  Chap.  XII.)  are  present  in 
profusion  in  every  case  of  genuine  fibrinous  pneumonia.  A 
simple  glance  does  not  suffice,  however,  to  base  a  diagnosis 
on,  since  it  is  difficult  to  distinguish  them  from  harmless 
fungi.  They  may  be  recognized  with  certainty  if  one  emul- 
sifies a  quantity  of  sputum  with  sterilized  water  and  injects 
this  subcutaneously  into  a  rabbit.  If  the  sputum  contain 
virulent  pneumococci,  the  rabbit  will  die  of  septicaemia  in 
from  1  to  3  days,  and  its  blood  and  the  fluid  from  its  en- 
larged spleen  will  contain  innumerable  diplococci.  The 
expectorated  material  employed  must  be  free  from  saliva 
and  bronchial  mucus  and  must  be  positively  from  the  lungs; 
for  pneumococci  are  present  in  the  mouths  of  healthy  jjersons 
and  are  therefore  also  called  the  cocci  of  sputum  septicaemia. 

To  cleanse  the  pulmonary  sputum,  as  above  mentioned,  it 
is  received  in  a  sterilized  Petri's  dish;  it  is  washed  with 
sterilized  water,  transferred  to  another  similar  dish  with 
sterilized  forceps,  is  again  washed  in  sterile  water,  etc. 
After  this  process  is  repeated  five  or  six  times,  it  may  be 
safely  assumed  that  the  sputum  is  free  from  contamination, 
and  may  be  employed  for  purposes  of  culture  or  inoculation 
{Koches  washing  method). 

Inßnenza  bacilli  (Chap.  XII.)  are  found  abundantly  in 
the  bronchitis  and  pneumonia  of  influenza.  The  micro- 
scopic examination  does  not  always  answer,  and  it  may  be 
necessary  to  make  a  culture. 

Tubercle  bwÄlli.  Their  demonstration  is  the  keystone 
of  the  diagnosis  of  tubercular  phthisis  of  the  lungs.  In 
doubtful  cases,  especially  in  the  early  stages,  the  proof  of 
their  presence  is  of  the  highest  importance.     The  finding 


VI  DISEASES   OF   THE    RESPIKATOKY   TRACT  151 

of  tubercle  bacilli  in  the  sputum  proves  with  certainty  the 
diagnosis  of  tuberculosis.  A  negative  result,  on  the  other 
hand,  does  not  speak  absolutely  against  the  diagnosis.  For 
the  technic  of  staining,  see  Chap.  XII.  If  difficulties  pre- 
sent themselves,  the  method  of  Biedert  may  offer  some  ad- 
vantages. A  teaspoonful  of  sputum,  with  3  teaspoonfuls  of 
water  and  15  drops  of  potassium  hydrate,  are  boiled  for 
2  hours  over  a  sand-bath.  The  greater  part  of  the  pus  is 
dissolved.  In  the  sediment  remaining,  even  a  few  bacilli 
may  be  stained  easily  and  with  certainty. 

Anthrax  bacilli  and  the  club-like  ends  of  actinomj/ces  have  been 
occasionally  found  in  the  sputum  as  proof  of  the  existing  disease. 
So  have  chains  of  aspergillus  and  t\\e  fungus  of  thrush  in  the  sputum 
of  pneumonomycosis. 

Symptoms  of  the  Diseases  of  the  Luxgs 

Bronchitis.  —  Cough  and  expectoration,  frequently  pain  in 
the  chest,  usually  no  marked  emaciation.  Physical  exami- 
nation :  no  dulness,  vesicular  breathing  often  accompanied 
by  prolonged  sharpened  expiration,  diffuse  dry  rales. 
Sputum,  in  acute  cases,  glassy,  mucous,  clinging  tenaciously 
to  the  bottom  of  the  containing  vessel ;  in  chronic  cases, 
muco-purulent,  with  no  characteristic  elements.  Signs  of 
bronchitis  in  one  apex  only  justify  the  suspicion  of  begin- 
ning tuberculosis  {catarrlius  unius  lateris  non  est  catarrJms). 
It  is  worthy  of  note  that  signs  of  acute  bronchitis  arise 
secondarily :  in  cardiac  disease  (bronchitis  of  stasis),  and 
in  the  acute  infectious  diseases,  as  in  typhoid  fever.  Prog- 
nosis of  simple  acute  bronchitis,  with  proper  treatment, 
good.  Chronic  bronchitis  leads  to  emphysema  and  dilata- 
tion of  the  right  heart,  and  runs  its  course,  frequently,  with 
attacks  of  bronchial  asthma. 

Chronic  bronchitis  may  lead,  through  retention  of  the 
secretions,  to  sac-like  dilatations  of  the  smaller  air-passages 


152  DISEASES   OF   THE   RESPIRATORY   TRACT        chap. 

(bronchiectasis).  Small  bronchiectases  usually  escape  diag- 
nosis. In  large  bronchiectases,  there  may  be  a  marked 
stagnation  of  pus,  which  undergoes  putrefaction  (see  fetid 
bronchitis).  The  sputum,  in  such  cases,  is  expectorated  in 
the  morning  frequently  by  mouthfuls,  and  arranges  itself 
in  three  layers.  Large  bronchiectases  give  the  physical 
signs  of  cavities ;  they  usually  occupy  the  lower  lobes,  and 
may  be  concealed  by  the  corresponding  compression  of  the 
tissues  of  the  lungs. 

The  etiological  irritation  which  is  the  cause  of  bronchitis  (dust, 
etc.)  may  also  evoke  interstitial  inflammation  in  the  lung,  which 
may  lead  to  formation  of  connective  tissue,  and  to  contraction 
(interstitial  fibrous  pneumonia,  cirrhosis  of  the  lung,  pneumo- 
coniosis). Bronchitis  may  also,  in  this  way,  be  responsible  for 
areas  of  dulness.  It  must  not  be  forgotten  that  tubercle  bacilli 
usually  find  their  way  into  lungs  saturated  with  dust  and  irritated 
by  it;  and  in  practice  it  has  this  significance,  —  that  bronchitis 
with  dulness  denotes  tuberculosis.  The  final  decision  will  rest 
upon  the  finding  of  tubercle  bacilli. 

Emphysema  (volumen  pxdmoniim  auctum).  —  Shortness  of 
breath  and  cyanosis,  usually  cough  and  expectoration. 
Barrel-shaped  chest.  Often  dilated  veins  on  both  sides  of 
the  chest.  Lower  border  of  the  lung  lower  than  usual ; 
absence  or  diminution  of  cardiac  dulness.  Vesicular  breath- 
ing diminished  in  intensity.     Frequently,  dry  rales. 

The  prognosis  depends  upon  the  degree  of  preservation  of  the 
respiratory  motility  of  the  lungs ;  in  very  advanced  cases,  the  limit 
of  the  expiratory  position  of  the  lower  border  of  the  lungs  is  from 
^  to  1  cm.  from  their  most  extended  inspiratory  position.  Some 
observers  reserve  the  name  emphysema  for  those  serious  cases  prog- 
nostically,  in  which  the  alveoli  undergo  necrosis,  because  of  the 
pressure  prevailing  in  them,  thus  producing  a  typical  (Laennec's) 
emphysema,  in  which  air,  to  a  certain  extent,  penetrates  the  tis- 
sues. If  one  employs  the  word  emphysema  in  this  limited  sense, 
the  phrase  volumen  pulmonum  auctum  would  serve  well  for  all  those 
cases  of  moderate  and  milder  forms  which  represent  clinically  a 
completer  conservation  of  respiratory  normality. 


VI  DISEASES    OF   THE  RESriRATORY   TRACT  153 

Pneumonia  {genuine,  croiqjous,  lobar).  —  Sudden  beginning 
with  chill,  pain  in  the  side  of  the  chest,  cough.  High  con- 
tinuous fever.  Ivubiginous  sputum.  Physical  signs,  —  1st 
stage  (engorgement)  :  tympanitic,  slightly  dull  note  over 
the  infiltrated  (lower)  lobe  ;  crepitant  rales  ;  in  the  2d  stage 
(hepatization),  complete  dulness  ;  bronchial  breathing.  In- 
creased vocal  fremitus,  od  stage  (resorption  or  resolution)  : 
gradual  clearing  up  of  the  dulness,  the  bronchial  breathing 
gradually  becomes  vesicular ;  fine  and  coarse  rales  may  be 
heard.  Prognosis  :  usually  favorable  ;  crisis  between  the  3d 
and  11th  days,  resolution  of  the  exudate  (disappearance  of 
dulness)  in  1  to  4  weeks.  In  weakened  persons,  the  resolu- 
tion may  require  months  (as  much  as  1-^  years)  (delayed 
resolution).  Fever  of  remittent  type  lasting  longer  than  11 
days  points  to  complication  or  sequelae,  especially  pleurisy 
(empyema) ;  rare  issues  are  carnification  (formation  of  granu- 
lation tissue  in  the  exudate  with  subsequent  connective  tis- 
sue formation  and  contraction),  cheesy  degeneration,  abscess, 
gangrene.  Prognosis  for  healthy  young  persons  usually 
good ;  in  individual  cases  the  prognosis  depends  particularly 
upon  the  condition  of  the  heart  (pulse)  and  the  involvement 
of  the  mental  faculties.  Prognosis  grave  in  drunkards,  aged 
people,  cardiac  cases,  and  persons  with  kypho-scoliosis. 

Broncho-pneumonia  (secondary,  catarrhal,  lobular).  —  Fol- 
lows bronchitis,  usually  in  acute  infectious  diseases :  moder- 
ate dulness  often  with  a  tympanitic  sound,  with  bronchial 
breathing  and  moist  rales,  over  circumscribed  areas  most 
frequently  involving  both  lower  lobes.  Remittent  fever  of 
long  continuance,  sputum  usually  muco-purulent,  colorless. 
Appears  chiefly  in  children  and  the  aged,  frequently  in 
stuporous  patients  who  aspirate  particles  of  food  (aspiration 
pneumonia). 

The  prognosis  of  a  broncho-pneumonia  is  always  grave; 
recovery  is  possible,  though  most  frequently  death  occurs 
as  a  result  of  exhaustion,  tuberculosis,  or  gangrene. 


loi  DISEASES   OF   THE    RESPIRATORY   TRACT        chap. 

Dry  pleurisy  {pleuritis  sicca)  is  diagnosticated  by  the  pres- 
ence of  localized  friction  sounds,  which  are  equally  loud  on 
inspiration  and  expiration,  and  may  frequently  be  felt. 
Pain  and  usually  fever,  Not  rarely  caused  by  exposure  to 
cold.     Often  present  in  tuberculosis. 

Pleurisy  with  effusion  {pleuritis  exsudativa).  —  Begins  sud- 
denly with  a  chill  and  pain  in  the  side,  or  the  pain  may 
come  on  gradually ;  frequently  low  degree  of  dyspnoea. 
Fever  irregular,  remittent.  Absolute  dulness  (flatness)  be- 
low posteriorly,  respiratory  murmur  and  pectoral  fremitus 
diminished  or  absent.  Above  the  border  of  dulness,  on 
account  of  the  compression  of  the  lung,  often  a  tympanitic, 
slightly  dulled  percussion  note,  bronchial  breathing,  very 
fine  rales  (atelectasis).  Apex-beat  and  cardiac  dulness 
frequently  displaced.  When  the  effusion  is  on  the  left 
side,  the  semilunar  space  is  usually  diminished. 

The  upper  border  of  the  dulness  is  situated  differently,  accord- 
ing as  the  patient  lay  or  walked  about  during  the  formation  of  the 
effusion.  In  the  first  instance,  especially  among  the  better  classes, 
the  border  of  dulness  runs  diagonally  from  above  posteriorly  to 
below  anteriorly;  if  the  patient  had  been  walking  about  (as  is 
frequently  the  case  among  hospital  patients),  the  upper  border 
is  almost  a  horizontal  line.  During  the  stage  of  resolution  the 
upper  border  often  forms  a  convex  curve  pointing  upward,  the 
highest  point  of  which  lies  in  the  side  of  the  chest  (the  curve  of 
Ellis  and  Damoiseau).  By  the  change  of  position  of  the  jDatient 
the  l)order  of  dulness  fixed  b}'  inflammatory  adhesions  is  altered 
slowly  or  not  at  all. 

After  a  pleuritic  effusion  is  diagnosticated,  the  nature  of 
the  exudate  must  be  determined,  whether  it  is  serous  (simple 
pleurisy),  purulent  (empyema),  or  hmmorrhagic  (usually  de- 
pendent upon  a  malignant  new  growth).  Although  the 
patient's  condition  of  strength,  the  character  of  the  fever, 
the  pulse,  and  the  respiration  must  be  considered  in  making 
a  differential  diagnosis,  an  (aseptic)  exploratory  puncture 
with  a  hypodermic  syringe  must  be  undertaken  to  settle 


VI  DISEASES   OF  THE   KESPIRATORY   TRACT  155 

the  diagnosis.     It  should  never  be  omitted  in  any  case  of 
pleural  effusion. 

In  considering  serous  effusions,  it  nuist  be  noted  that  it  is  fre- 
quently evoked  by  a  primary  disease  of  the  lungs  (particularly 
tuberculosis,  next  in  importance  pneumonia,  infarct,  gangrene, 
abscess).  One  should  not  be  satisfied,  therefore,  with  the  diagnosis 
"serous  pleurisy,"  but  should  examine  the  lungs,  and,  if  necessary, 
the  sputum,  in  order  to  ascertain  the  etiological  factors  of  the 
pleurisy.  It  is  important  to  remember  in  this  connection  that 
many  signs  of  tuberculosis  of  the  lungs  lose  their  importance 
when  found  above  a  pleural  effusion ;  for  dulness,  bronchial 
breathing,  and  crepitant  rales  may  arise  as  well  from  compression 
of  the  lung. 

Aside  from  diseases  of  the  lung,  other  things  that  may  produce 
pleurisy  are  :  diseases  of  the  heart  and  kidneys,  inflammatory  con- 
ditions of  the  liver,  circumscribed  peritonitis,  particularly  appendi- 
citis, possibly  lues ;  as  complications  of  acute  infectious  diseases, 
pleuritis  not  infrequently  arises,  just  as  do  inflammations  of  other 
serous  surfaces  (pericarditis,  endocarditis). 

In  purulent  effusions,  the  treatment  and  prognosis  are  mainly 
dependent  upon  the  determination  of  the  etiology;  aside  from 
the  history,  many  cases  require  a  bacteriological  examination  of 
the  bacteria  contained  in  the  pus  obtained  from  the  exploratory 
puncture. 

Pneumococci  in  the  pus  denote  meta-jmeumonia,  tubercle  bacilli 
tubercular  empyema.  Streptococci  and  staphylococci  give  no  cer- 
tain evidence  as  to  the  origin  of  the  disease  ;  in  tubercular  disease 
of  the  lungs,  empyema  dependent  upon  streptococci  and  staphylo- 
cocci may  arise.  Bacilli  of  putrefaction  are  found  in  empyema  in 
gangrene  of  the  lungs  or  in  embolic  infarcts  of  rotten  purulent 
processes,  especially  in  puerperal  infections.  The  continued  absence 
of  bacteria  in  the  pus  speaks  for  tuberculosis. 

In  many  cases  during  and  after  the  resolution  of  pleural 
effusions,  adhesions  between  the  two  layers  of  the  pleura 
spring  up  with  the  formation  of  thick  connective  tissue 
{pleuritis  retrahens).  The  pleuritic  thickenings  manifest 
about  the  same  physical  signs  as  the  effusion  (dulness, 
diminution  of  the  respiratory  murmur,  and  the  vocal  frem- 
itus), yet  they  differ  in  this  respect,  that  they  show^  signs 


156  DISEASES   OF   THE    RESPIRATORY   TRACT        chap. 

of  retraction  and  of  tension  on  neighboring  organs  (flatten- 
ing and  drawing  in  of  one  side  of  the  thorax,  displacement 
of  the  heart,  or  increased  size  of  the  semilunar  space).  . 

Phthisis  pulmonum.  —  The  first  stage  may  give  evidence 
of  no  physical  changes  in  the  thorax.  The  suspicion  of 
tuberculosis  is  aroused  by  various  uncertain  symptoms: 
a  hacking  cough,  little  expectoration,  headache,  easy  fatigue, 
loss  of  appetite,  gastric  disturbances,  loss  of  flesh  and 
strength ;  an  hereditary  taint  and  the  habitus  paralyticus 
make  the  aspect  of  the  case  more  serious.  The  (early) 
diagnosis  can  be  made  with  certainty  only  by  the  presence 
of  tubercle  bacilli  in  the  sputum. 

A  rise  of  temperature  following  an  injection  of  Koch's  old  tuber- 
culin may  be  counted  as  one  of  the  signs  which  enable  an  early 
diagnosis  to  be  made.  Although  convalescents  and  weakened  per- 
sons with  healthy  lungs  may  also  show  a  rise  of  temperature  after 
small  doses,  still  the  fever  induced  by  the  subcutaneous  injection  of 
from  1  to  5  mg.  of  tuberculin  speaks  very  much  in  favor  of  tubercu- 
losis. These  injections  are  not  without  some  danger,  however,  and 
are  scarcely  to  be  commended  for  use  in  private  practice. 

It  is  important,  for  diagnostic  purposes,  to  discover  possible 
sources  of  infection  :  residence  with  tubercular  patients  (wife  or 
husband,  brother  or  sister,  other  occupants  of  the  same  house). 

The  first  appreciable  physical  signs  are :  distinct  dulness 
over  one  apex ;  vesicular  respiration  with  sharpened,  pro- 
longed expiration  or  broncho- vesicular  breathing ;  fine,  non- 
metallic  or  bronchitic  rales. 

In  a  further  advanced  stage,  marked  emaciation,  profuse 
cough  and  expectoration.  Sputum  large  quantity,  muco- 
purulent, often  in  little  balls;  contains  elastic  fibres  and 
tubercle  bacilli.  Intense  dulness  over  the  apex  and  below 
the  clavicle,  bronchial  breathing,  profuse,  coarse  rales  with 
something  of  a  metallic  ring. 

In  the  final  stage,  extreme -emaciation,  very  profuse  cough 
and  expectoration,  sputum  in  balls  and  falling  to  the  bottom 


VI  DISEASES   OF   THE    RESPIRATORY   TRACT  157 

of  a  vessel.  Physical  examination :  in  part  extensive  areas 
of  clulness,  in  part  a  loud  tympanitic  note  (even  the  lower 
lobe  is  sometimes  attacked),  bronchial  breathing,  tinkling, 
coarse  rales,  in  places  change  of  sound  in  the  percussion 
note. 

Prognosis  in  the  very  beginning  with  the  possibility  of 
thorough  treatment,  inclined  to  be  good ;  in  the  more  ad- 
vanced stages,  usually  bad.  Complication,  in  the  beginning, 
usually  pleurisy ;  other  possible  complications :  pneumo- 
thorax, miliary  tuberculosis,  tuberculosis  of  other  organs 
(larynx,  intestine,  tubercular  meningitis,  peritonitis,  etc.), 
general  amyloid  degeneration. 

Pneumothorax. — Earely  seen  in  the  healthy  (trauma,  fract- 
ure of  ribs,  over-exertion)  ;  usually  secondary  to  phthisis, 
gangrene,  abscess,  perforating  emp3^ema,  emphysema.  The 
physical  signs  are :  — 

Dilatation  of  the  affected  side  and  its  immobility  in  the 
existing  dyspnoeic  breathing.  Percussion  :  abnormally  loud, 
deep  note  (usually  not  tympanitic),  metallic  note-  when  the 
hainmer  and  pleximeter  are  used.  Auscultation :  if  the 
cavity-opening  is  closed,  no  respiratory  murmur ;  if  it  is 
open,  amphoric  breathing.  A  fluid  effusion  usually  takes 
place  soon;  sero-  or  pyo-pneumothorax  (exploratory  punct- 
ure) ;  above  the  fluid,  dulness  with  no  respiratory  murmur 
and  no  vocal  fremitus  ;  instantaneous  change  in  the  borders 
of  the  dulness  on  change  of  position.  Metallic  splashing 
sound  on  shaking  the  thorax  from  side  to  side,  audible  at 
quite  a  distance  (succussio  Hipi^ocratis).  The  prognosis  de- 
pends upon  the  primary  disease  and  the  possibility  of  opera- 
tive interference.     Prognosis  in  the  healthy,  good. 

Fetid  bronchitis  is  diagnosticated  Avhen  the  sputum  is  foul- 
smelling  (nose  and  throat  not  being  involved),  when  no 
characteristic  elements  aside  from  the  fetid  plugs  are  formed 
in  the  expectoration,  and  when  there  is  no  dulness  over  the 
lungs  and  the  signs  of  bronchitis  only  are  present. 


158  DISEASES   OF   THE   RESPIRATORY    TRACT       chap. 

The  prognosis  depends  upon  the  intensity  of  the  bronchitis  or 
npon  tlie  presence  of  bronchiectasis  and  upon  the  general  symp- 
toms evoked  by  the  putrescence.  Fetid  bronchitis,  with  no  septic 
manifestations,  usually  oifers  a  good  prognosis.  Fetid  bronchitis 
frequently  leads  to  large  bronchiectases  which  may  firmly  com- 
press the  sun-oundiiig  tissue.  In  this  manner,  a  putrid  bronchitis 
may  call  forth  dulness  (in  the  lower  lobes). 

Gangrene  of  the  lungs  is  diagnosticated  from  the  putrid 
expectoration,  which  contains  fragments  of  lung  tissue  in 
addition  to  fetid  plugs  (p.  149),  and  the  physical  demonstra- 
tion of  the  necrotic  area  of  lung :  dulness,  bronchial  breath- 
ing, moist  rales. 

The  diagnosis  must  also  establish  the  cause  of  the  gan- 
grene, which  modifies  the  prognosis :  trauma  (usually  great 
pressure),  pneumonia  (frequently  after  influenza),  embolus, 
perforating  putrid  abscess  of  the  bronchial  glands,  perforat- 
ing putrid  empyema,  extension  of  gangrenous  foci  from  the 
oesophagus,  vertebrae,  intestines,  liver. 

As  far  as  the  prognosis  is  concerned,  there  must  be  determined : 
(1)  the  extent  of  the  local  disease:  in  circumscribed  gangrene 
without  perceptible  formation  of  cavities,  prognosis  inclined  to 
be  good ;  in  diffuse  gangrene  with  formation  of  cavities,  prognosis 
bad;  (2)  the  cause  of  the  gangrene:  injury  and  pneumonia, 
empyema,  bronchial  abscesses,  give  comparatively  a  good  prog- 
nosis ;  suppurating  emboli,  extension  from  the  oesophagus,  verte- 
brae, etc.,  usually  a  bad  prognosis;  (3)  the  general  symptoms: 
signs  of  severe  infection  (very  rapid  pulse,  delirium  and  collapse) 
are  of  evil  omen . 

Haemorrhagic  infarct  of  the  lung  is  diagnosticated  when  in  con- 
ditions which  accompany  the  possibility  of  local  thromhos^is  (Puerpe- 
rium, marasmus,  wounds,  decubitus,  etc.,  especially  dilatation  of  the 
riffht  heart)  there  are  sudden  stitches  in  the  side,  cough,  and  bloody 
sputum  often  accompanied  by  fever.  The  diagnosis  is  made  more 
certain  by  the  demonstration  of  a  circumscribed  infiltration 
(dulness,  diminished  or  bronchial  breathing,  rales),  frequently 
an  additional  pleural  effusion.  The  prognosis  depends  upon  the 
cause  of  the  embolus  and  the  bodily  strength  ;  small  infarcts,  not 
infected,  are  readily  absorbed. 


VI  DISEASES   OF   THE   RESPIRATORY  TRACT         159 

Abscess  of  the  lung  is  diagnosticated  from  purulent  sputum 
containing  elastic  fibres  ivithout  tubercle  ])acilli,  with  remittent 
fever,  when  the  cause  of  the  abscess  (pneumonia,  infected  infarct, 
injury)  may  be  simultaneously  proven  and  the  signs  of  infiltration 
or  of  a  cavity  are  present.  Prognosis  dependent  upon  the  cause 
and  the  general  manifestations ;  a  favorable  outcome  lies  in  per- 
foration into  a  bronchus  and  subsequent  healing. 

Tumor  of  the  lung  (carcinoma  or  sarcoma)  produces  local  dul- 
ness,  over  which  may  usually  be  heard  bronchial  breathing  or 
rales.  The  cutaneous  veins  in  the  region  of  the  dulness  are  usu- 
ally dilated  and  frequently  the  veins  of  the  corresponding  arm  are 
involved.  In  many  cases,  a  sputum  like  raspberry  jelly  is  expec- 
torated. Sometimes  a  haemorrhagic  effusion  into  the  pleura  occurs, 
often  a  swelling  of  the  axillary  glands.  Cachexia  sets  in  during 
the  course  of  the  disease. 

Echinococcus  of  the  lung  can  be  diagnosticated  only  when  the 
signs  of  a  tumor  are  present  and  when  echinococcus  cysts  are  found 
in  the  sputum. 

Syphilis  of  the  lung  must  be  considered  from  the  diagnostic 
point  when  a  diffuse  infiltration  or  contraction  presents  itself, 
when  tertiary  syphilis  is  known  to  be  present  and  tuberculosis  is 
excluded.  The  proof  of  the  diagnosis  lies  in  the  successful  issue 
of  specific  treatment. 

Actinomycosis  of  the  lungs.  —  Signs  of.  infiltration  and  cavity  for- 
mation in  the  lungs,  with  considerable  secondary  pleurisy.  The 
diagnosis  is  made  more  positive  by  the  demonstration  of  the  pres- 
ence of  the  ray  fungus  in  yellow  granulations  contained  in  the 
sputum. 


CHAPTER  VII 

DIAGNOSIS  OF  THE  DISEASES  OF  THE  CIRCULATORY 

SYSTEM 

For  the  anamnesis,  the  following  things  must  be  considered : 
1.  The  previous  life  of  the  patient :  excessive  jjJiysical  exertion  and 
great  psychical  excitement  cause  idiopathic  cardiac  disease.  Too 
luxurious  eating  and  drinking  produce  increased  blood  pressure 
followed  by  arterial  sclerosis  and  heart-disease.  Too  good  living 
produces  obesity  {fatty  heart).  Alcoholism  evokes  cardiac  weakness ; 
too  much  smoking,  neurotic  conditions  of  the  heart.  2.  Previous 
diseases :  acute  articular  rheumatism,  not  quite  so  frequently  all  the 
other  acute  infectious  diseases  (scarlatina,  erysipelas,  malaria,  etc.), 
leads  to  endocarditis  or  myocarditis.  Syphilis  may  be  the  cause  of 
a  myocarditis.  3.  Previous  symptoms  of  heart  and  kidney  diseases 
possibly  present. 

The  diagnosis  of  diseases  of  the  heart  is  supported  by 
subjective  symptoms :  abnormal  sensations  in  the  cardiac 
region,  palpitation  of  the  heart,  a  sense  of  anxiety ;  by  the 
presence  of  dyspnoea,  cyanosis,  and  oedema,  and  by  the 
results  of  the  physical  examination  of  the  heart  and  blood- 
vessels. 

Complaiyits  of  cardiac  difficulties  (palpitation,  sense  of 
anxiety,  etc.)  without  real  dyspnoea,  without  cyanosis  and 
oedema  and  in  the  absence  of  physical  anomalies,  are  to  be 
referred  to  nervous  affections  of  the  heart. 

Tachycardia,  increased  rapidity  of  the  j^ulse,  is  often  seen  in  ner- 
vous affections  of  the  heart  in  consequence  of  excitement,  excesses, 
etc.,  and  as  a  result  of  certain  digestive  disturbances  and  sometimes 
without  appreciable  reason  (cf.  p.  171). 

Anyina  pectoris  is  a  severe  pain  in  the  region  of  the  heart  com- 

1Ü0 


CHAP.  VII     DISEASES  OF  THE  CIRCULATORY  SYSTEM      161 

ing  on  in  attacks,  usually  witli  pain  extending  toward  the  left  arm 
and  accompanied  by  the  most  exquisite  sensations  of  anguish  and 
anxiety.  It  may  appear  in  any  severe  cardiac  disease,  especially 
in  sclerosis  of  the  coronary  arteries  (/mgirm  pectoris  vera  seu 
Heherderni).  Painful  attacks  like  those  of  angina  pectoris  may 
arise  in  neurasthenics  (angina  pectoris  neurasthenica) ;  in  these 
cases  there  are  usually  other  symptoms  on  the  part  of  the  vaso- 
motor system  present,  such  as  alternate  flushing  and  pallor  of  the 
face  and  arms.  In  every  case,  angina  pectoris  is  to  be  regarded  as 
a  serious  matter  which  demands  the  closest  examination  of  the 
circulatory  apparatus. 

Eor  a  discussion  of  dyspnoea,  cyanosis,  and  oedema,  see 
pp.  10,  125. 

Cardiac  asthma  is  the  name  given  to  attacks  of  dyspnoea  in  car- 
diac disease,  which  last  for  hours,  more  rarely  for  days,  and  which 
are  follow^ed  by  intervals  of  freedom ;  it  may  appear  whenever 
there  is  dilatation  of  the  left  ventricle.  The  differential  diagnosis 
as  to  bronchial  asthma  rests  upon  the  estahlishnent  of  the  dilated 
ventricle  and  the  small,  rapid,  irregular  pulse. 

In  attacks  of  asthma  of  doubtful  etiology  the  greatest  value 
must  be  placed  on  the  examination  of  the  heart,  particularly  the 
palpation  of  the  apex-beat  and  the  feeling  of  the  pulse.  In  bron- 
chial asthma  the  heart  is  healthy.  In  other  respects,  the  two  diseases 
may  simulate  each  other  closely,  since  in  all  w^eakened  conditions  of 
the  left  heart,  a  bronchitis  due  to  congestion  and  a  secondary  emphy- 
sema may  arise  (expansion  of  the  lung  due  to  distention  of  the  pul- 
monary vessels) .  A  characteristic  difference  is  often  seen  in  the 
character  of  the  sputum  (see  p.  147).  In  bronchial  asthma  the 
expectoration  is  tenacious,  glassy,  mucous,  with  whitish-yellow 
lumps,  containing,  on  microscopic  examination,  crystals,  spirals, 
and  eosinophile  cells ;  the  sputum  of  cardiac  asthma  usually  shows 
the  presence  of  blood  and  approximates  in  appearance  that  of 
oedema  of  the  lungs.  Microscopically,  alveolar  epithelium  is  often 
to  be  seen . 

The  oedema  of  cardiac  disease  begins  at  the  ankles  and  slowly 
ascends ;  it  attacks  last  the  hands,  arms,  and  face ;  the  oedema  of 
Bright's  disease  usually  begins  in  the  face. 

Albuminuria  in  heart-disease  appears  only  when  a  high  degree  of 
stasis  is  present ;  at  the  same  time  the  urine  is  scanty  and  of  high 
specific  gravity  (see  below). 

31 


162        DISEASES   OF   THE   CIRCULATORY   SYSTEM      chap. 

The  objective  examination  of  the  heart  consists  of  inspec- 
tion and  palpation,  percussion  and  auscultation  of  the  heart 
and  great  vessels,  examination  of  the  radial  pulse  and  of 
the  urine. 

IXSPECTIOX    AXD    PalPATIOX 

The  position  smd  force  of  the  impulse  of  the  heart  and  of  the 
apexnheat  must  be  determined. 

The  impulse  of  the  heciH  denotes  the  impulse  of  the  sys- 
tole, the  elevation  of  the  entire  cardiac  area ;  the  apex-beat 
is  the  visible  and  palpable  expansion  of  the  intercostal  space 
furthest  to  the  left,  external  and  inferior. 

1.  Position  of  the  apex-heat.  In  healthy  persons,  the  hand 
placed  over  the  cardiac  area  feels  a  weak,  systolic  impulse ; 
the  apex-beat  is  to  be  felt  in  the  5th  intercostal  space  mid- 
way between  the  parasternal  and  mamillary  lines. 

In  children  the  apex-beat  is  frequently  somewhat  higher,  in  the 
aged  one  intercostal  space  lower ;  in  deep  inspiration  the  apex-beat 
sinks  a  little  lower.  With  the  patient  lying  on  the  left  side  the 
apex-beat  may  be  moved  a  finger's  breadth  to  the  left;  this  is 
especially  true  of  rapidly  emaciating  persons,  when  the  patient 
turns  to  the  right  side  the  apex-beat  soon  recovers  its  normal 
position. 

Permanent  displacement  of  the  apex-beat  is  of  great  diag- 
nostic importance  ;  it  denotes  either  dilatation  or  compression 
of  the  heart. 

Displojcement  of  the  apex-heat  toward  the  left  signifies 
(a)  dilatation  of  the  left  side  of  the  heart,  (h)  dislodgment  of 
the  entire  heart  toward  the  left ;  in  the  latter  cases  a 
pleural  effusion  or  pneumothorax  exists  on  the  right  side, 
in  rarer  instances  a  tumor  may  be  demonstrated,  or  there 
may  be  a  retracted  pleura  on  the  left  side. 

Displacement  of  the  apex-beat  toward  the  tight  always  de- 
pends upon  a  dislodf/ment  of  the  heart,  through  a  pleuritic 
effusion  or  pneumothorax  on  the  left  side,  or  a  retracted 
pleura  on  the  right  side. 


vn  DISEASES   OF   THE   CIRCULATORY   SYSTEM         163 

Displacemeyit  of  the  apex-heat  doicnivard  may  occur  through 
hypertrophy  of  the  left  ventricle,  less  often  aneurysm  of  the 
aorta,  or  unusually  deep  attachments  of  the  diaphragm. 

Displacement  of  the  apex-heat  iqnvard  takes  place  only 
when  the  diaphragm  is  pushed  up  in  consequence  of  extraor- 
dinary distention  of  the  abdomen  (ascites,  meteorism,  dila- 
tation of  the  stomach,  tumors,  pregnancy). 

2.  Force  of  the  cardiac  impidse  and  apex-heat.  A  diminu- 
tion in  the  force  of  the  cardiac  impidse  and  apesc-heat  to  a 
point  at  which  neither  can  be  felt  may  occur :  (1)  in  very 
fat  persons ;  (2)  when  the  lung  overlaps  the  heart :  emphy- 
sema ;  (3)  when  the  pericardium  is  distended  with  fluid, 
more  rarely  when  there  is  a  tumor  of  the  pericardium; 
(4)  in  all  zceakened  conditions  of  the  heart. 

In  many  healthy  persons,  however,  the  apex-beat  is  never  felt 
because  it  strikes  against  the  rib  instead  of  in  the  intercostal  space. 

Increased  force  of  the  cardiac  impulse  and  apex-heat.  An 
"elevating"  impulse  is  imparted  to  the  hand.  It  is  present : 
(1)  in  physiologically  increased  cardiac  activity,  when  there  is 
psychical  excitement,  great  exertion,  in  fever ;  (2)  in  hyper- 
trophy of  the  heart ;  (3)  often  in  dilatation  of  the  heart  when 
the  apex-beat  is  also  displaced  outward. 

While  the  diminished  force  of  the  apex-beat  frequently  speaks 
for  cardiac  weakness  in  persons  who  are  not  very  fat  and  not 
emphysematous,  its  increased  force  by  no  means  indicates  an  m- 
creased  cardiac  strength.  Martins  established  the  fact  that  the 
appreciation  of  the  cardiac  impulse  depends  not  only  upon  the 
functional  activity  of  the  heart,  but  upon  the  cardiac  area  exposed 
to  the  thoracic  wall.  According  to  Martins,  the  systole  of  the 
ventricle  may  be  divided  into  two  periods.  It  first  contracts  with 
closed  aortic  valves ;  by  this  manoeuvre  its  form  is  changed  in  a 
typical  way,  producing  the  cardiac  impulse,  but  its  volume  is  un- 
changed (^period  of  closure).  During  the  second  period  of  the 
systole  the  aortic  valves  open,  the  volume  of  the  ventricle  is 
diminished  {period  of  expulsion').  This  is  the  explanation,  too,  of 
the  fact  that  very  weak,  dilated  hearts  with  a  small  pulse  often 


164        DISEASES   OF   THE   CIRCULATORY   SYSTEM       chap. 

give  a  decided  impulse  ;  during  the  period  of  closure  a  much  larger 
cardiac  volume  than  normally  is  impelled  against  the  chest-wall, 
and  much  less  blood  is  sent  into  the  aorta  during  the  period  of 
expulsion  than  from  a  healthy  heart. 

Sounds  or  murmurs  felt  by  palpation  have  the  signili- 
cance  as  when  appreciated  by^  auscultation.  The  thrill 
palpable  over  stenosed  cardiac  valves  is  particularly  worthy 
of  note.  At  the  apex  a  presystolic  thrill  is  characteristic  of 
mitral  stenosis ;  at  the  right  edge  of  the  sternum  in  the  2d 
intercostal  space  a  systolic  thrill  is  characteristic  of  aortic 
stenosis.     (Aneurysm  must  not  be  forgotten,  however.) 

A  bulging  of  the  cardiac  area  speaks  for  dilatation  and 
hypertrophy  of  the  heart  or  pericardial  effusion,  although 
rhachitic  changes  in  the  bones  must  be  borne  in  mind. 

A  systolic  retraction  of  the  5th  intercostal  space  by  the 
apex-beat  occurs  only  when  the  two  layers  of  the  pericardial 
sac  are  adherent  in  consequence  of  chronic  pericarditis ;  the 
pulsus  paradoxus  is  often  present  (p.  173). 

Visible  pulsations  (synchronous  with  the  radial  pulse) : 
over  the  aorta  or  pulmonary  artery  denote  aneurysm  or  an 
infiltration  of  the  corresponding  lobe  of  the  lung;  in  the 
epigastrium,  frequently  of  no  diagnostic  significance  (when 
the  diaphragm  lies  low),  more  often  depending  upon  dilata- 
tion of  the  right  ventricle.  Visible  pulsations  of  the  liver, 
synchronous  with  a  venous  pulse,  have  the  same  meaning  as 
the  actual  venous  pulse  (tricuspid  insufficiency). 

Venous  pulsations,  visible  at  the  bulb  of  the  jugular  vein 
or  in  the  jugular  vein  if  the  valves  of  the  bulb  are  insuffi- 
cient, are  either  synchronous  with  the  systole  of  the  heart 
(actual  venous  pulse,  presystolic-systolic),  or  they  precede 
the  cardiac  systole  (diastolic-presystolic)  (cf.  p.  176). 

An  actual  venous  pulse  is  the  principal  sign  of  tricuspid 
insufficiency ;  the  presystolic  venous  pulse  is  often  seen  in 
conditions  of  venous  congestion  without  valvular  insuffi- 
ciency. 


vn  DISEASES   OF  THE   CIRCULATORY   SYSTEM        165 


Pekcussion  of  TiiK  Hkakt 

Normal  limits  of  cardiac  duhiess.  The  internal  border 
runs  along  the  left  edge  of  the  sternum  ;  the  external  border 
forms  a  somewhat  convex  arch  directed  outward  from  the 
4th  costal  cartilage  to  the  5th  intercostal  space,  between  the 
mamillary  and  parasternal  lines  (apex-beat).  The  upper 
border  lies  at  the  lower  edge  of  the  4tli  rib,  the  lower  border 
upon  the  Gth  rib,  although  this  can  not  always  be  accurately 
determined  because  of  the  encroaching  liver  dulness. 

The  limits  described  are  those  of  uhaohite  flatness,  i.e.,  within 
these  limits  the  dulness  is  intense;  beyond  these  limits  the  so- 
called  "  relative  dulness  "  lies,  above  as  high  as  the  upper  border 
of  the  'M  rib,  to  the  right  as  far  as  the  median  line ;  but  this 
"  relative  dulness "  is  normally  not  very  intense. 

In  children  the  area  of  cardiac  duhiess  is  somewhat  greater,  in 
the  aged  somewhat  smaller.  Every  deep  inspiration  diminishes 
the  area.  With  the  patient  lying  on  the  left  side,  the  external 
border  moves  outward  about  one  finger's  breadth. 

The  increased  area  of  cardiac  dulness  is  one  of  the  principal 
signs  of  advanced  heart-disease.  Lateral  extension  of  the 
dulness  usually  denotes  dilatation  of  the  ventricle.  Dilata- 
tion is  the  second  stage  in  most  cardiac  diseases,  and  arises 
from  hypertrophy. 

1.  Extension  of  the  cardiac  dulness  to  the  left  over  the 
mamillary  line  denotes  dilatation  of  the  left  ventricle ;  this 
is  induced  by  aortic  insufficiency  or  stenosis,  by  mitral  in- 
sufficiency, and  by  the  causes  of  idio^jathic  heart-disease 
(see  p.  176). 

2.  Extension  of  the  cardiac  dulness  toward  the  light  be- 
yond the  left  border  of  the  sternum  points  to  dilatation  of 
the  right  ventricle,  although  a  similar  note  evoked  over  the 
lower  half  of  the  sternum  may  be  due  to  a  mere  collection 
of  fat ;  dilatation  of  the  right  ventricle  arises  in  mitral 
stenosis  and   insufficiency,  in  valvular  lesions  of  the  right 


166        DISEASES   OF   THE   CIRCULATORY   SYSTEM      chap. 

side  of  the  heart  as  well  as  in  emphysema,  kypho-scoliosis, 
retracted  pleurae. 

3.  Simultaneous  expansion  of  the  cardiac  dulness  toward 
both  sides  and  upivard  denotes  a  fluid  effusion  into  the  peri- 
cardium (pericarditis  or  hydro-pericardium).  The  area  of 
dulness  forms  an  equilateral  triangle  the  apex  of  which  lies 
in  the  3d  to  the  1st  intercostal  spaces. 

In  every  case  of  enlargement  of  the  area  of  cardiac  duhiess,  it 
must  be  decided  whether  there  is  an  actual  dilatation  (increase  of 
volume),  or  whether  there  is  (1)  a  displacement  of  the  entire  heart, 
(2)  a  withdrawal  of  the  lung  covering  the  heart  so  that  a  greater 
cardiac  area  lies  directly  against  the  chest-wall.  The  cardiac  diü- 
ness  is  changed  in  place  by  pneumothorax,  pleuritic  effusions, 
tumors,  retracting  processes  of  the  pleurae  and  lungs ;  the  area  is 
freed  from  a  covering  of  pulmonary  tissue  in  retraction  of  the 
lung  ;  the  heart  is  likewise  brought  nearer  the  chest-wall  by  up- 
ward pressure  of  the  diaphragm  (ascites,  pregnancy,  etc.).  In 
cases  of  transposition  of  the  viscera  the  entire  heart  lies  on  the 
right  side,  the  liver  on  the  left. 

Hypertrophy  of  the  heart  is  usually  not  demonstrable  by 
percussion;  only  after  dilatation  is  added  to  the  hyper- 
trophy can  one  make  the  percutory  demonstration. 

Hypertrophy  of  the  left  ventricle  is  diagnosticated  by  the 
powerful  apex-beat,  accompanied  by  an  abnormally  high  ten- 
sion of  the  radial  artery,  accentuation  of  the  systolic  mitral 
and  the  diastolic  aortic  sounds. 

Hyx^ertrophy  of  the  right  ventricle  is  diagnosticated  by 
the  abnormal  accentuation  of  the  diastolic  pulmonic  sound. 

Diminution  or  absence  of  the  cardiac  area  of  dulness  is 
found  when  the  over-distended  lung  covers  the  heart  (em- 
physema). 

The  entrance  of  air  into  the  pericardium  { pueumo-pericardium) 
produces  a  tympanitic  or  metallic  percussion  note  over  the  area  of 
cardiac  dulness;  this  is  a  fatal,  very  rare  phenomenon  caused  by 
perforation  of  an  ulcer  of  the  stomach  or  the  contents  of  a  lung 
cavity  into  the  pericardium. 


VII  DISEASES   OF  THE   CIRCULATORY   SYSTEM        167 

Dulness  over  the  upper  part  of  the  sternum^  or  directly  next 
to  it,  is  diagnostic  of  aneurysm  of  the  arch  of  the  aorta  or 
of  a  mediastinal  tumor ;  in  very  rare  cases,  of  an  enlarged 
thymus  gland  or  of  a  sub-sternal  goitre. 

AUSCULTATIOX    OF    THE    HeART 

The  auscultation  of  the  heart  shows  whether  or  not  there 
are  valvular  lesions  present ;  these  lesions  are  recognized  by 
characteristic  murmurs.  Clear  heart-sounds  denote  the  in- 
tactness  of  the  valves ;  but  despite  this  fact,  the  heart  may 
be  diseased,  hypertrophic,  or  dilated.  Dilatation  and  hyper- 
tropjhy  of  the  heart  in  the  X)resence  of  dear  tones  rest  upon 
disease  of  the  cardiac  muscle  (idiopathic  heart-disease). 

Normal  axd  Intensified  Sounds 

The  sounds  of  the  mitral  valve  are  auscultated  at  the  apex, 
those  of  the  tricuspid  at  the  right  border  of  the  sternum  at 
the  5th  and  6th  costal  cartilage ;  the  sounds  of  the  aortic 
valves  are  best  heard  at  the  right  border  of  the  sternum  in 
the  2d  intercostal  space  ;  those  of  the  pulmonic  valves  at  the 
left  border  of  the  sternum  in  the  2d  intercostal  space. 

Over  each  valve  are  heard  a  systolic  sound  during  the 
contraction  of  the  ventricles  and  a  diastolic  sound  during 
the  dilatation  of  the  ventricles. 

Over  the  mitral  and  tricuspid  valves  ouly  one  sound  is  heard, 
the  systolic,  produced  by  the  tension  of  the  valves  and  the  con- 
traction of  the  muscles  of  the  ventricles  ;  the  diastolic  sound  is 
carried  away  by  the  aortic  in  the  one  case,  by  the  pulmonic  in  the 
other.  Over  the  arterial  openings,  two  sounds  arise,  the  systolic, 
produced  by  the  tension  of  the  expanded  vessels,  the  diastolic, 
through  closure  of  the  valves. 

Over  the  mitral  and  tricuspid  valves,  the  systolic  sound 
is  normally  somewhat  louder  than  the  diastolic ;   over  the 


168         DISEASES   OF   THE   CIRCULATORY    SYSTEM       chap. 

aorta  and  pulmonary  artery  the  diastolic  is  normally  some- 
what louder  than  the  systolic. 

Abnormal  intensification  of  the  mitral  systolic  sound  in 
hypertrophy  of  the  left  ventricle  and  in  physiologically  in- 
creased activity  of  the  heart  (exertion,  excitement) ;  also 
in  fever. 

Abnormal  diminution  of  the  mitral  systolic  sound  in  all 
weakened  conditions  of  the  left  ventricle  (often  dilated). 

Abnormal  intensification  of  the  2d  pulmonic  sound  denotes 
hypertrophy  of  the  right  ventricle. 

Abnormal  intensification  of  the  2d  aortic  sound  denotes 
hypertrophy  of  the  left  ventricle. 

A  musical  timbre  in  the  heart-sounds  does  not  allow  of  essential 
diagnostic  discrimination ;  it  is  usually  produced  by  an  increased 
tension  of  the  flaps  of  the  valves. 

A  metallic  sound  of  the  cardiac  sounds  (often  to  be  heard  at  some 
distance)  proves  the  presence  of  large  spaces  of  air  near  the  heart ; 
also  heard  in  cavities  of  the  lung,  dilatation  of  the  stomach,  and 
in  the  very  rare,  fatal  cases  of  the  entrance  of  air  into  the  peri- 
cardium (pneumo-pericardium). 

Reduplication  of  the  heart-sounds  is  of  little  diagnostic  value. 
It  occurs  in  the  healthy  and  is  particularly  frequent  in  the  systolic 
sounds  heard  at  the  apex  in  hypertrophy  following  contraction  of 
the  kidney.  Reduplication  of  the  diastolic  sound  in  consequence 
of  mitral  stenosis. 

Murmurs 

Systolic  and  diastolic  murmurs  are  distinguished ;  their  nomen- 
clature depends  upon  the  fact  whether  or  not  they  are  synchro- 
nous with  the  cardiac  impulse  (or  pulse)  or  not.  A  diastolic 
murmur  which  immediately  precedes  the  impulse  of  the  heart  is 
called,  presystolic.  A  murmur  occurs  simultaneously  with  a  heart- 
sound,  or  after  it,  or  with  no  relation  to  the  sounds. 

The  murmurs  are  best  heard  in  a  direction  perpendicular 
to  the  current  of  blood  which  produces  them.  Auscultation 
in  mitral  insufficiency  is  therefore  practised  in  the  2d  left 
intercostal  space ;   in  aortic  insufficiency  the  diastolic  mur- 


VII  DISEASES   OF   THE    CIRCULATORY    SYSTEM         169 

mur  is  best  auscultated  at  the  middle  of  the  sternum  or  at 
the  left  border  of  the  sternum  in  the  3d  intercostal  space. 

A  systolic  murmur  over  the  mitral  denotes  insufficiency  of 
the  mitral.  This  murmur  may  depend  upon  anatomical 
changes  (endocarditis)  ;  it  may,  however,  be  functional  or 
accidental. 

Accidental  murmurs  are  produced  by  a  turning  over  of  the 
borders  of  the  valve  in  consequence  of  undue  stretching  of  the 
papillary  muscles  or  by  relative  insufficiency  in  consequence  of 
dilatation  of  the  ventricle.  Accidental  murmurs  are  soft,  blowing, 
usually  heard  only  as  systolic  murmurs. 

A  systolic  murmur  at  the  apex  is  regarded  as  functional, 
if  the  patient  has  fever,  is  anmmic  or  poorly  nourished^  and 
the  murmurs  disappear  with  time.  It  may  be  referred  to 
an  endocarditis,  when  a  sufficient  etiology  can  be  gathered 
(especially  articular  rheumatism)  and  other  symptoms  of 
valvular  lesions  are  present  (accentuation  of  the  2d  pul- 
monic, dilatation  of  the  right  ventricle,  etc.). 

Diastolic  {presystolic)  murmur  over  the  mitral  denotes 
mitral  stenosis. 

Systolic  murmur  over  the  aorta  is  diagnostic  of  aortic 
stenosis. 

Diastolic  murmur  over  the  aorta  signifies  aortic  insuffi- 
ciency caused  by  endocarditis  or  arterio-sclerosis. 

If  two  murmurs  are  heard,  the  greatest  importance  is  to 
be  attached  to  the  diastolic. 

Diastolic  murmurs  are  but  rarely  accidental,  while  systolic  mur- 
murs frequently  rest  upon  a  functional  basis. 

The  force  and  the  character  of  the  murmur  offer  a  small 
basis  as  to  the  prognosis  of  the  valvular  lesion. 

The  force  of  the  murmur  is  only  in  part  dependent  upon  the 
severity  of  the  anatomical  change ;  of  greater  importance  are  the 
rapidity  of  the  blood-current,  the  smoothness  or  roughness  of 
the  walls  of  the  valves.  The  character  of  murmurs  is  described 
as  blowing,  grating,  scratching,  etc. 


170         DISEASES   OF   THE   CIRCULATORY   SYSTEM       chap. 

Pericardial  friction  sounds  are  not  synchronous  with  the 
heart's  beat,  seem  to  be  nearer  to  the  ear  on  auscultation 
than  endocardial  murmurs,  often  heard  at  irregular  inter- 
missions (puffing  murmurs).  They  prove  the  presence  of 
fibrinous  deposits  on  the  pericardium  (pericarditis  ßbrinosa). 
They  are  independent  of  the  respiration,  but  are  influenced 
by  very  deep  inspiration. 

Extra-peri  cardial  friction  sounds,  arising  between  the 
pleura  and  the  external  layer  of  the  pericardium,  have  the 
character  of  pleuritic  friction  sounds,  usually  of  a  crackling 
nature,  are  dependent  for  their  production  upon  the  respira- 
tion, and  disappear  when  the  breath  is  held. 

AUSCULTATTOX    OF    THE    VESSELS 

The  auscultation  of  the  vessels  sometimes  helps  to  establish  the 
diagnosis  of  a  valvular  lesion. 

The  systole  of  the  heart  corresponds  to  the  diastole  of  the  ves- 
sels ;  heart's  systole  =  vessel's  diastole ;  heart's  diastole  =  vessel's 
systole. 

The  carotid  is  best  auscultated  at  the  inner  margin  of  sterno- 
cleido-inastoid  muscle  at  the  level  of  the  thyreoid  cartilage ;  the 
subclavian  in  the  outer  portion  of  the  supra-clavicular  fossa. 

Over  the  carotid  and  the  subclavian  one  hears  normally  two 
sounds,  the  first  (cardiac  systole)  arises  from  tension  of  the  wall 
of  the  vessel ;  the  second  (cardiac  diastole)  is  transmitted  from  the 
aortic  valves. 

In  aortic  insufficiencij  a  sawing,  systolic  murmur  is  heard  over 
the  carotids,  because  of  the  extraordinarily  sudden  tension  of  the 
walls  of  the  carotid  at  the  instant  of  the  entrance  of  the  current 
of  blood ;  the  second  sound  is  missing,  however,  as  it  is  not  formed 
by  the  aortic  valves.  A  systolic  murmur  may  frequently  be  heard 
by  transmission  from  the  heart  in  aortic  stenosis,  mitral  insuffi- 
ciency, and  general  arterio-sclerosis. 

The  more  distant  arteries  may  also  be  auscultated  (the  femoral 
in  the  groin,  the  brachial  at  the  bend  of  the  elbow,  the  radial  above 
the  wrist).  In  healthy  persons  no  sounds  or  murmurs  are  heard 
in  these  vessels;  by  pressing  the  stethoscope  upon  the  artery  a 
murmur  produced  by  pressure  may  be  elicited  (arterial  diastolic 


VII 


DISEASES   OF   TUE    CIRCULATORY   SYSTEM         171 


murmur :  by  very  hard  pressure,  this  is  perceived  by  the  ear  as  a 
clear  sound).  An  abnormal  sound  is  found  in  aortic  insufficiency 
even  in  the  smaller  vessels  (in  the  palm  of  the  hand,  in  the  fore- 
arm, etc.).  A  double  tone  is  heard  in  the  femoral  in  aortic  insuffi- 
ciency, mitral  stenosis,  pregnancy,  lead  colic. 

Actual  mimnurs,  audible  without  pressure,  heard  over  peripheral 
arteries  prove  the  presence  of  an  aneurysm,  and  are  usually 
palpable. 

Normally,  nothing  is  heard  over  the  veins.  The  jugular  vein 
may  be  auscultated  at  the  outer  margin  of  the  sterno-cleido- 
mastoid  muscle  at  the  level  of  the  thyreoid  cartilage. 

In  all  cases  of  anaemia  and  chlorosis,  a  loud  humming  murmur 
may  be  heard  over  the  jugular  vein,  which  sounds  loudest  when 
the  patient  turns  his  head  to  the  opposite  side.  Over  the  femoral 
vein  a  murmur  may  be  heard  only  in  anseniia  of  great  intensity. 

The  Pulse 

The  frequency  of  the  pulse  in  healthy  adults  varies  from 
60  to  80  beats  a  minute,  in  children  from  100  to  140,  in  the 
aged  from  70  to  90. 

Sloimng  of  the  pulse  (brachycardia,  pulsus  rarus)  is  of 
diagnostic  value  only  under  certain  circumstances.  It  is 
found  in  the  most  widely  different  conditions,  evoked  by 
irritation  of  the  vagus,  or  paralysis  of  the  sympathetic,  or 
irritation  or  paralysis  of  the  cardiac  centres.  Brachycardia 
in  exhaustion,  after  a  crisis  or  at  the  beginning  of  convales- 
cence, is  especially  noteworthy.  It  is  found  in  meningitis 
(pressure  on  the  brain),  in  jauyidice  (action  of  the  biliary- 
acids),  and  in  colic  in  which  it  offers  a  point  in  differential 
diagnosis  between  it  and  peritonitis.  A  slowing  of  the 
pulse  occurs  most  frequently  in  stenosis  of  the  aortic  and 
mitral  valves  among  the  cardiac  diseases,  as  well  as  in  some 
idiopathic  heart-diseases  (coronary  sclerosis)  and  as  a  result 
of  the  action  of  digitalis. 

Rapidity  of  the  pulse  (tachycardia,  pulsus  frequens)  evoked 
by  paralysis  of  the  vagus,  irritation  of  the  sympathetic,  or 
affections  of  the  cardiac  ganglia,     formal  after  physical 


1T2        DISEASES   OF   THE   CIRCULATORY   SYSTEM      chap. 

exertion,  psychical  irritation,  and  after  eating ;  pathological 
in  all  febrile  diseases  (with  each  degree  of  temperature  the 
pulse  is  increased  8  beats  a  minute),  common  in  convales- 
cence from  them;  in  all  febrile  diseases  which  lead  to  con- 
sumption (phthisis,  anaemia,  etc.). 

Excessive  rapidity  (over  160)  is  a  sign  of  great  weakness 
of  the  heart  (collapse). 

Tachycardia  is  a  sign  of  disturbed  compensation  in  cardiac 
diseases  and  is  often  proportional  to  the  intensity  of  the 
disturbance.  Tachycardia  is  also  one  of  the  principal  symp- 
toms of  neurotic  disease  of  the  heart,  and  when  it  a^^pears 
in  attacks,  forms  a  particular  disease  (paroxysmal  tachy- 
cardia). 

Tachycardia  with  exophthalmos,  goitre,  and  tremor  of  the 
fingers,  frequently  associated  with  general  cachexia,  forms 
the  symptom-complex  of  Basedow^s  disease. 

The  rhythm  of  the  pulse.  Irregularity  of  the  pulse 
(arythmia)  is  present  in  many  cardiac  diseases  without 
offering  points  for  differential  diagnosis.  Arythmia  of  mild 
character  is  not  uncommon  among  nervous  people,  after 
excitement,  excesses,  gastric  disturbances,  in  constipation ; 
sometimes  no  reason  can  be  assigned  for  it.  Although 
arythmia  always  demands  a  careful  examination  of  the 
heart,  the  diagnosis  of  a  cardiac  disease  should  not  be  made 
from  this  symptom  alone. 

Embryocnrdia  is  the  equalization  of  the  systole  and  diastole 
through  the  absence  of  tlie  normal  pause  following  the  diastole. 
The  heart-beats  sound  like  the  tick-tack  of  a  clock,  like  the  foetal 
heart-sounds.  Enibryocardia  is  often  the  expression  of  a  very 
weak  heart. 

Characteristic  types  of  irregular  pulse  are:  Pulsus  alternans: 
two  heart-contractions  correspond  to  one  pulse-beat,  or  the  second 
pulse-beat  is  but  feebly  to  be  felt.  Pulsus  hujeminus:  every  third 
beat  of  the  pulse  is  omitted.  Pulsus  trigeminus :  every  fourth  pulsa- 
tion is  omitted.  No  diagnostic  conclusions  can  be  reached  from 
these  irregularities. 


VII 


DISEASES   OF   THE    CIRCULATORY    SYSTEM         173 


Pulsus  jxtnidoxus :  in  deep  inspiration,  the  pulse  becomes  small 
or  disappears  ;  appeal's  in  adhesions  of  the  layers  of  the  pericar- 
dium, mediastinitis  with  cicati-isation  or  adhesions,  mediastinal 
tumors,  stenosis  of  the  air-passages. 

Unequal  rebound  of  the  pulse  at  symmetrical  arteries,  or  a 
delayed  pulse  in  corresponding  arteries,  is  a  symptom  of  aneurysm. 
The  former  condition  may  be  due,  however,  to  congenital  anoma- 
lies of  the  arteries. 

Velocity  of  the  pulse  (quick  or  slow) :  the  pulse  is  rapid 
or  slow  according  to  the  rapidity  or  slowness  of  the  expan- 
sion and  collapse  of  the  arterial  w^all.  A  rapid  jndse  (j)ulsus 
celer)  is  found  in  all  conditions  of  increased  cardiac  activity, 
particularly  hypertrophy  of  the  left  ventricle.  It  is  char- 
acteristic of  aortic  insufficiency  (pulsus  celer  et  altus),  con- 
tracted kidney,  Basedow^ s  disease,  etc.  A  sloiv  jndse  (^9?(Zs?/s 
tardus)  is  seen  in  the  aged,  in  aortic  and  mitral  stenosis,  in 
aneurysms. 

The  tension  of  the  pulse  (large  or  small,  high  or  low^) : 
the  height  of  the  pulse-wave  depends  upon  the  strength  of 
the  heart,  the  amount  of  blood  in  the  arteries,  and  the  ten- 
sion of  the  arteries.  A  high-tension  pulse  is  present  in 
fever,  hypertrophy  of  the  heart,  especially  in  aortic  insuffi- 
ciency ;  a  small  pulse  is  a  sign  of  cardiac  w^eakness,  charac- 
teristic among  valvular  lesions,  of  stenosis. 

Hardness  of  the  pulse  (hard  or  soft,  durus  or  mollis) : 
this  quality  depends  upon  the  tension  of  the  arterial  walls 
and  is  proportional  to  the  strength  which  must  be  used  by 
the  examining  finger  to  compress  the  pulse.  Hard  pulse  in 
hypertrophy  of  the  left  ventricle  (wiry  in  contracted  kid- 
ney), as  well  as  in  tetanic  contraction  of  the  arterial  mus- 
cles. Soft  pulse  in  anaemia  and  fever.  Hard  pulse  in 
arteriosclerosis  due  to  dej^osits  of  lime  in  the  w^alls  of  the 
arteries :  the  artery  may  be  rolled  under  the  finger. 


174        DISEASES   OF  THE   CIRCULATORY    SYSTEM      chap. 


Sphygmographic  Tracings  (Figs.  30-33) 

The  purpose  of  sphygmographic  tracings  of  the  pulse- 
curve  is  to  reach  precision  in  the  recognition  of  the  changes 
in  the  pulse  by  objective  means.  A  diagnosis  may  be  sup- 
ported by  such  tracings. 

An  ascending  and  a  descending  limb  is  seen  in  sphygmographic 
curves.  Elevations  arising  from  the  ascending  limb  are  called 
anacrotic;  arising  from  the  descending  limb,  katacrotic.  In  the 
normal  pulse  of  adults,  the  ascending  limb  rises  almost  perpen- 
dicularly. Anacrotic  elevations  appear  only  in  disease  of  the 
heart  or  arteries,  the  expansion  of  the  arteries  occurring  in  inter- 
missions. The  descending  limb  has  normally  a  decided  elevation  : 
the  dicrotic  wave,  produced  by  the  falling  back  of  the  blood  against 
the  aortic  valves ;  and  several  minor  waves  (waves  of  elasticity, 
tidal  and  jiostdicrotic)  evoked  by  the  elasticity  of  the  arterial  wall. 
The  tidal  waves  are  marked  when  the  walls  of  the  artery  are 
under  tension,  as  in  lead  colic.  At  the  same  time  the  dicrotic 
wave  is  small.  The  tidal  wave  is  very  small  or  disappears  alto- 
gether in  a  soft  artery  under  low  tension ;  the  dicrotic  wave  then 
becomes  prominent  and  is  appreciated  by  the  finger  as  a  second, 
weak  pulsation  :  this  is  dicrotism  of  the  pulse. 

Dicrotism  is  found  in  febrile  disease,  especially  in  typhoid.  In 
tracings,  the  dicrotic  wave  appears  in  various  types  according  as  its 
record  appears  above  or  below  the  base  line  :  in  a  predicrotic  pulse 
the  elevation  begins  before  the  descending  limb  reaches  the  base 
line  (moderate  fever) ;  in  a  dicrotic  pulse,  as  the  descending  limb 
reaches  the  base  line ;  in  a  postdicrotic  pulse  it  begins  below  the 
base  line  (higher  fever).  In  the  tracing  of  a  monocrotic  pulse 
(very  high  fever),  no  dicrotism  is  noticeable. 

Pulsus  tardus  shows  a  slowly  rising  ascending  limb,  a  rounded 
summit,  no  tidal  wave,  no  dicrotic  wave  (senile  pulse).  Pulsus 
celer  et  alt  us  has  a  perpendicular  ascending  limb,  no  dicrotic  eleva- 
tion, several  tidal  waves. 

The  venous  pulse  shows  a  negative  picture  of  the  arterial  pulse. 
The  anacrotic  limb  is  long  drawn  out  and  possesses  a  notch  (ana- 
dicrotic),  the  katacrotic  falls  almost  perpendicularly  (katamono- 
crotic).  The  second  limb  of  the  tracing  corresponds  to  the  systole 
of  the  right  auricle,  the  katamonocrotic  limb  to  the  ventricular 
contraction   (auricular  diastole).     On    tho  other  hand,  in   insuffi- 


VII  DISEASES   OF   THE    CIRCULATOIIY   SYSTEM        175 


Fig.  30. — Si'hyg.mugkaphic  Tracing  of  the  Kadial  Akteky  of  a  Healthy 

Young  Man. 


Fig.  31. — Spiiygmographic  Tracing  of  the  Eadial  Artery  in  Aortic 

Insufficiency, 


Fig.  32. — Sphygmographic  Tracing  of  the  Eadial  Artery  in  Aortic  Stenosis. 


Fig.  33.  —  Spuyg-mourapuic  Tracing  or  the  Eadial  Artery  in  Mitral  Stenosis. 


176        DISEASES  OF  THE   CIRCULATORY   SYSTEM      chap. 

ciency  of  the  tricuspid,  the  expansion  of  the  vein  due  to  the  systole 
of  the  auricle  does  not  follow  the  systolic  collapse  of  the  heart, 
but  there  is  an  additional  expansion  synchronous  with  the  ventricular 
systole.  The  collapse  of  the  vein  takes  place  in  the  next  diastole. 
The  '*  actual  "  venous  pulse  begins,  then,  in  the  ventricular  diastole 
(auricular  systole),  lasts  throughout  the  entire  systole,  and  ends 
only  at  the  beginning  of  the  following  diastole  (cf.  p.  164). 

The  Examination  of  the  Urine  in  Cardiac  Cases 

Since  the  excretion  of  the  urine  is  dependent,  in  part, 
upon  the  arterial  blood-pressure,  a  diminution  of  the  arte- 
rial or  increase  of  the  venous  blood-pressure  is  recognized 
in  the  diminished  amount  of  urine.  In  cases  of  cardiac 
weakness  or  disturbed  compensation  the  urine  is  scant, 
dark-red,  of  high  specific  gravity,  with  2:)rofuse  brick-red 
sediment,  frequently  containing  a  trace  of  albumin. 

In  congestive  conditions  of  long  standing,  a  secondary  nephritis 
may  develop  with  hyaline  and  granular  casts  in  the  sediment ;  the 
nephritis  of  congestion  may  even  lead  to  granular  atrophy. 

The  improvement  in  the  heart-disease  shows  itself  plainly 
in  the  increased  amount  of  urine  and  the  disappearance  of 
the  albuminuria. 

Symptoms  of  the  Most  Important  Cardiac  Diseases 

Common  symptoms  to  all  these  diseases  are  :  in  the  stage 
of  compensation,  absence  of  any  essential  difficulties;  in  the 
stage  of  disturbed  compensation  :  cyanosis,  dyspnoea,  oedema, 
urine  of  consrestion. 


'Ö' 


Idiopathic  Cardiac  Diseases 

Hypertrophy,  or  dilatation  of  the  ventricle,  with  clear 
tones,  or  even  the  systolic  murmur  of  relative  insufficiency. 

Prolonged  over-activity  of  the  left  ventricle  in  arterio- 
sclerosis, chronic  nephritis  and  contracted  kidiiey,  over-exertion 


vii  DISEASES   OF   THE   CIRCULATORY   SYSTEM         177 

for  a  long  periocl,  over-indulgence  in  drink  (beer  heart), — 
all  these  factors  aid  in  production  of  hypertrophy  of  the  left 
ventricle  with  subsequent  dilatation. 

Cardiac  weakness  without  a  previous  hypertrophy,  partly 
with  and  partly  without  dilatation  of  the  heart  (dehilitas 
cordis,  weak  heart),  is  developed  (1)  by  the  action  of  toxic 
substances  upon  the  heart-muscle :  alcoholism  (whiskey 
drinking),  excessive  use  of  tobacco,  infectious  toxines  (myo- 
carditis after  diphtheria,  typhoid,  etc.) ;  (2)  by  improper 
nourishment:  inanition,  anaemia,  senility. 

Hypertrophy  of  the  right  ventricle,  with  subsequent  dila- 
tation, arises  in  all  obstructions  to  the  pulmonary  circulation 
(emphysema,  pleural  thickenings,  kypho-scoliosis). 

A  faify  heart  is  the  heart  which  gives  disagreeable  phenomena 
to  very  stout  people.  Cardiac  difficulties  of  the  first  degree  are 
those  produced  by  the  deposit  of  fat  in  the  abdomen  as  well  as  in 
the  pericardium;  difficulties  of  greater  intensity  are  referable  to 
the  growth  of  fat  into  the  heart-muscle.  "When  the  cardiac  muscle 
undergoes  fatty  degeneration,  troubles  of  the  most  serious  nature 
are  evoked,  leading  even  to  death.  As  fatty  degeneration  of  the 
heart  is  mostly  the  ultimate  outcome  of  fatty  deposits  about  the 
heart,  man}'  writers  think  that  the  expression  "fatty  heart"  should 
be  reserved  for  this  final  stage,  and  a  term  expressive  of  "  cardiac 
weakness "  should  be  employed  for  the  cardiac  troubles  of  the 
obese. 

Valvular  Lesions 

yahn.ilar  lesions  are  the  result  of  valvular  endocarditis, 
which  is  productive  of  contraction  (insufficiency)  or  adhe- 
sions (stenosis)  of  the  flaps  of  the  valves.  The  endocarditis 
is  usually  a  sequel  of  the  acute  infectious  diseases,  particu- 
larly of  articular  rheumatism.  Besides  this  etiology,  arterio- 
sclerosis may  act  as  a  cause. 

When  the  valvular  lesion  is  completed,  hypertrophy,  and, 
later,  dilatation  ensues,  in  consequence  of  the  forced  increase 
of  function  on  the  part  of  the  ventricle.     In  aortic  lesions 

N 


178        DISEASES   OF  THE    CIRCULATORY   SYSTEM      chap. 

it  is  the  left,  in  mitral  lesions  the  right  ventricle  which  is 
thus  affected. 

Aortic  insufficiency  (frequent).  Marked  cardiac  impulse, 
apex-beat  displaced  to  the  left  and  downward,  cardiac 
dulness  extended  to  the  left.  Diastolic  murmur  in  the 
direction  of  the  blood-current  regurgitating  from  the  aorta. 
Best  heard  in  the  middle  of  the  sternum  and  to  the  left 
of  it  in  the  3d  intercostal  space.  Frequently  a  systolic 
murmur  at  the  apex  and  accentuated  2d  pulmonic  sound. 
Pulsus  celer  et  altus.  Strong  pulsation  of  the  carotids; 
systolic  murmur  in  the  carotids  with  absence  of  the.  2d 
sound.     Humming  sound  in  the  femoral.     Capillary  pulse. 

Aortic  stenosis  (rarely  alone).  Weak  cardiac  impulse, 
apex-beat  displaced  to  the  left  and  downward,  but  much 
less  than  in  insufficiency.  Cardiac  dulness  extended  to  the 
left.  Loud  systolic  murmur  over  the  aorta  (frequently 
fremissement  cataire) ;  heard  much  weaker  over  the  other 
valves.  Second  aortic  sound  weak  or  absent.  Pulse  small, 
of  low  tension,  slow.  Frequently  facial  pallor ;  sometimes 
syncope,  convulsions,  attacks  of  vertigo. 

Mitral  insufficiency  (most  common  valvular  lesion).  Car- 
diac impulse  moderately  strong,  apex-beat  frequently  dis- 
placed to  the  left.  Cardiac  dulness  extended  to  the  right. 
At  the  apex'  and  the  pulmonic,  a  systolic  murmur ;  2d  pul- 
monic sound  much  accentuated.  Marked  dilatation  of  the 
right  ventricle  is  accompanied  by  congestion  of  the  liver 
and  venous  pulse. 

Mitral  stenosis  (rarely  alone).  Cardiac  impulse  quite 
marked,  epigastric  pulsation  common.  Cardiac  dulness 
extended  to  the  right.  At  the  apex  a  presystolic  murmur 
(heqnentlj  fremissement  cataire),  intensified,  rough,  systolic 
sound.  Forcible  closure  of  the  pulmonic  valve.  Pulse  slow 
and  small,  slightly  irregular. 

Tricuspid  insufficiency.  Cardiac  dulness  extended  to  the 
right,  systolic  murmur  over  the  tricuspid  valve,  diminished 


VII  DISEASES   OF  TUE    CIRCULATORY   SYSTEM        179 

intensity  of  2d  pulmonic  sound,  actual  venous  pulse,  pulsa- 
tion of  the  liver.  Tlie  symptoms  of  this  disease  are  rarely 
due  to  anatomical  changes  in  the  valve,  but  are  more  fre- 
quently to  be  traced  to  relative  insufficiency  when  marked 
dilatation  of  the  right  ventricle  exists  as  a  common  sequel 
of  mitral  lesions. 

The  pulmonic  lesions  are  always  congenital  and  are  quite  rare. 
They  are  marked  by  deep  cyanosis,  the  cardiac  dulness  is  extended 
to  the  right,  and  the  nuirmurs  heard  correspond  to  the  lesion 
present. 

Pericakditis 

Cardiac  dulness  increased  in  area  in  the  form  of  an  equi- 
lateral triangle,  the  apex  of  which  points  upward.  The 
upper  limit  of  cardiac  dulness,  2d  to  3d  rib.  Cardiac  impulse 
and  apex-beat  weak  or  not  palpable ;  increased  in  intensity 
when  the  patient  bends  forward,  and  are  usually  felt  some- 
what internal  to  the  area  of  dulness.  Heart-sounds  very 
weak.  Friction  sounds  not  synchronous  with  the  cardiac 
beat  are  common.  Pain  in  the  region  of  the  heart  not 
uncommon  in  swallowäns 


Ö* 


Pericardial  plates  (coiicretio  pericaj'clii),  after  the  healing  of 
pericarditis,  sometimes  lead  to  the  symptoms  of  cardiac  weakness 
without  offering  percutory  or  auscultatory  signs.  In  some  cases 
the  diagnosis  is  made  possible  by  the  systolic  retraction  of  the 
region  of  the  apex-beat,  or  by  the  presence  of  pulsus  paradoxus. 


Symptoms  of  the  Prustcipal  Diseases  of  the  Large 

Blood-vessels 

Arterio-sclerosis  (atheroma  of  the  arteries).  —  The  palpable 
arteries  (especially  the  radial  and  temporal)  hard  and  tortu- 
ous, sometimes  uneven  and  rough.  Pulse  under  tension, 
mostly  sluggish.  Hypertrophy  and  dilatation  of  the  left 
ventricle.     Frequently  a  systolic  murmur  at  the  apex;  less 


180      DISEASES  OF  THE  CIRCULATORY  SYSTEM     chap,  vii 

often  a  diastolic  murmur  over  the  aorta.     Angina  pectoris 
or  cardiac  asthma,  common  (coronary  sclerosis). 

Atheroma  of  the  peripheral  arteries  does  not  always  indicate 
atheroma  of  the  large  vessels  and  of  the  heart.  On  the  other 
hand,  a  high  degree  of  sclerosis  of  the  aorta  (endaortitis)  may  be 
present,  without  any  apparent  disease  of  the  radial  arteries. 

Aneurysm  of  the  thoracic  aorta.  —  Dulness  over  the  upper 
part  of  the  sternum  and  its  neighborhood.  Over  this  area 
a  thrilling  systolic  or  diastolic  murmur,  audible  and  palpa- 
ble. As  the  disease  advances,  the  pulsating  tumor  appears 
to  the  left  of  the  sternum  in  the  region  of  the  2d  or  3d  rib. 
Frequently  hypertrophy  and  dilatation  of  the  left  ventricle. 
Unevenness  of  the  two  radial  pulses. 


CHAPTER   VIII 

THE  EXAMINATION   OF   THE   URINE 

By  the  examination  of  the  urine  we  obtain  information  of  :  — 

1.  The  condition  of  tJie  kidneys  and  of  the  bladder.  The  normal 
renal  epithelium  does  not  permit  the  albumin  in  the  blood  to  pass. 
In  kidney  disease,  albumin  and  histological  elements  appear  in  the 
urine.  Diseases  of  the  bladder  are  associated  with  definite  processes 
of  urinary  decomposition. 

2.  The  progress  of  the  metabolic  phenomena.  The  end  pi'oducts  of 
the  disintegration  of  the  albuminoids  (urea,  etc.)  are  voided  in  the 
urine ;  from  an  examination  of  this  excretion  we  can  determine  the 
quantitative  relations  existing  between  the  nitrogenous  income 
and  expenditure,  which  undergo  specific  changes  in  disorders  of 
metabolism,  as  well  as  the  admixture  of  certain  definite  compounds 
which  result  from  certain  anomalies  of  the  metabolic  processes,  or 
which  escape  the  chemical  change  or  conversion  which  they  should 
normally  undergo  (sugar,  acetone,  etc.). 

3.  The  force  of  the  heart  (see  p.  176). 

4.  Diseases  in  other  organs,  which  permit  certain  substances  to 
escape  into  the  blood  and  from  it  into  the  urine.  In  disease  of  the 
liver,  biliary  coloring  matter,  in  disease  of  the  intestine,  iudican, 
and  in  suppuration,  peptone,  appear  in  the  urine. 

5.  The  presence  of  heterogeneous  compounds  which  may  be  ad- 
ministered from  without,  such  as  iodine  and  mercury. 

The  quantity  of  urine  passed  in  24  hours  amounts  on  the 
average  to  1500  cc,  and  depends  within  further  limits  on 
the  amount  of  fluids  partaken  of.  A  daily  quantity  below 
500  cc.  and  above  3000  cc.  is  usually  an  indication  of  disease. 

Diminution  of  the  amount  of  urine  occurs  when  there  is 
profuse  perspiration  and  in  cases  of  diarrhoea,  in  fever,  in 
cardiac  weakness,  in  acute  and  often  in  chronic  nephritiS;  in 
cases  of  effusions  and  transudations. 

181 


182  THE   EXAMINATION   OF   THE   URINE  chap. 

In  cardiac  diseases  and  in  acute  nephritis  the  prognosis  as  to 
immediate  danger  is  for  the  most  part  made  from  the  amount  of 
urine  passed.  In  effusions,  e.g.,  pleuritic,  the  first  indication  of  the 
absorption  of  the  fluid  is  shown  by  an  increase  of  the  secretion  of 
urine.  The  excretion  of  a  small  amount  of  urine  is  often  a  sign  of 
deficient  nutrition. 

Increase  of  the  amount  of  urine  is  observed  in  diabetes 
mellitus  and  diabetes  insipidus,  in  atrophic  (small)  kidney, 
in  cases  of  effusions  and  transudations  when  absorption 
occurs,  and  often  during  the  period  of  convalescence  from  an 
acute  disease. 

The  specific  gravity  of  the  urine  varies  in  health  between 
1010  and  1025,  and  is  in  inverse  proportion  to  the  amount 
excreted. 

An  unusually  low  specific  gravity  occurs  in  contracted 
kidney  and  in  diabetes  insipidus.  A  very  high  specific 
gravity  is  observed  in  diabetes  mellitus,  in  fever  where  the 
amount  passed  is  small,  in  wasting  diseases,  and  in  nephritis. 

It  is  possible  to  determine  from  the  specific  gravity  the  amount 
of  the  solid  constituents  in  1000 cc.  of  the  urine  in  this  manner: 
multiply  the  last  two  ciphers  of  the  specific  gravity  by  2.33  (Häser's 
coefficient).  For  example,  should  the  urine  to  be  examined  have 
a  specific  gravity  of  1015,  then  15  x  2.33  =  34.95;  hence  the  solid 
constituents  in  the  urine  are  34.95  in  every  1000  cc. 

The  color  of  the  urine.  —  The  normal  color  of  the  urine  is 
a  more  or  less  deep  yellow;  the  smaller  the  quantity  the 
deeper  the  color.  It  is  of  a  deep  yellowish-red  color  when 
the  urine  contains  urobilin  (see  p.  192),  and  it  is  red  (like 
beef  solution)  when  it  contains  blood  (see  p.  190).  A  brown 
color  with  a  yellow  foam  indicates  the  presence  of  biliary 
coloring  matter  (see  p.  191).  In  carbolic  acid,  seldom  in  sali- 
cylic acid,  intoxication  the  color  varies  from  an  olive-green 
to  a  black.  It  is  yelloimsh-green  after  the  use  of  rhubarb  and 
santonin.  The  color  grows  darker  when  exposed  to  the  air, 
either  becavise  melanin  is  present  or  because  carbolic  acid 
was  taken  (see  p.  202). 


VIII  THE   EXAMINATION   OF  THE   URINE  183 

The  color  directs  our  attention  to  the  abnormal  elements 
which  the  urine  contains,  whereupon  these  may  be  detected 
by  a  chemical  and  microscopical  examination. 

Cloudy  urine.  —  Normal  urine  is  clear.  The  significance 
of  cloudy  urine  depends  on  its  reaction,  which  may  be  tested 
by  litmus  and  by  the  smell  (see  below). 

Cloudiness  of  acid  urine  is  owing  either  to  the  urates 
which  may  be  present,  and  in  this  case  the  urine  becomes 
clear  on  heating  in  a  test-tube,  or  to  organic  histological  ele- 
tnents  (see  below)  when  the  urine  will  not  become  clear  on 
heating.  These  anatomical  elements  may  be  detected  by 
the  use  of  the  microscope. 

The  organic  elements  consist  of  casts,  renal  epithelium,  or  pus 
cells.  Pas  is  detected  by  boiling  with  potassic  hydrate,  which  pro- 
duces a  mucilaginous  mixture. 

Cloudiness  of  alkaline  urine  arises  from  the  presence  of 
phosphates,  seldom  from  oxalate  of  lime,  or  from  organic 
elements  which  may  be  determined  by  the  use  of  the  micro- 
scope. 

On  the  addition  of  an  acid  the  cloudiness  arising  from  the  pres- 
ence of  salts  will  disappear,  whereas  it  will  naturally  not  be  dis- 
pelled when  organic  elements  give  rise  to  it.  Pus  is  determined 
here  also  by  the  mucilaginous  appearance  of  the  urine  when  boiled 
with  potassic  hydrate. 

The  reaction. — Normal  urine  is  acid.  Should  the  urine 
to  be  examined  be  alkaline,  we  must  determine  whether  this 
reaction  be  due  to  the  presence  of  a  fixed  alkali  (calcic  carbo- 
nate) or  to  a  volatile  one  (ammonium  carbonate).  This  is 
determined  by  holding  over  the  urine  a  piece  of  moistened 
red  litmus  paper.  Should  this  paper  turn  blue  without  agi- 
tating the  urine,  then  the  alkalinity  is  due  to  the  ammonium 
carbonate  in  the  urine ;  should,  on  the  other  hand,  the  blue 
color  result  only  after  dipping  the  paper  into  the  urine,  the 
alkalinity  is  due  to  the  presence  of  potassium  carbonate  or 


184  THE   EXAMINATION   OF   THE   URINE  chap. 

sodium  carbonate.  If  we  hold  a  glass  rod  moistened  with 
hydrochloric  acid  over  a  dish  containing  ammoniacal  urine, 
a  white  cloud  of  ammonium  chloride,  NH4CI  (sal  ammoniac), 
will  be  produced. 

The  reaction  of  the  urine  depends  upon  the  quantitative  relations 
existing  between  the  acids  and  bases.  Urnie  contains  the  following 
acids :  hydrochloric,  sulphuric,  phosphoric,  uric,  kreatin,  a  little 
hippuric  and  oxalic ;  the  following  bases  are  present :  potassium, 
sodium,  calcium,  magnesium,  ammonium,  kreatinin,  xanthin,  and 
hypoxanthin. 

By  the  disintegration  (metabolism)  of  the  albuminoids,  of  the 
lecithins,  and  of  nuclein,  sulphuric  acid  and  phosphoric  acid  are 
copiously  produced  ;  it  is  on  this  account  that  after  the  ingestion 
of  meat,  cheese,  legumens,  and  cereals,  the  urine  becomes  strongly 
acid. 

While  hydrochloric  acid  is  forming  compounds  in  the  stomach, 
in  the  first  act  of  the  digestion  of  a  meal  rich  in  albuminoids 
the  acid  reaction  of  the  urine  is  diminished ;  should  the  hydro- 
chloric acid  be  removed  by  vomiting  or  by  washing  out  the  stomach, 
the  urine  must  likewise  be  less  acid  and  more  alkaline. 

A  direct  increase  of  alkalinity  occurs  in  the  administration  of 
those  potassium  salts  whose  acids  are  easily  oxidized,  potassium  tar- 
trate, citrate,  and  malate,  which  are  oxidized  into  potassium  carbo- 
nate. These  salts  are  abundantly  present  in  fruits,  berries,  and  in 
potatoes.  The  eating  of  large  quantities  of  fruit  will,  therefore, 
render  the  urine  alkaline,  as  will  naturally  the  medicinal  adminis- 
tration of  sodium  carbonate. 

The  alkaline  reaction  of  the  urine  from  presence  of  a 
fixed  alkali  appears  soon  after  a  hearty  meal ;  after  a  hearty 
indulgence  in  fruits,  berries,  or  potatoes  ;  in  diseases  of  the 
stomach  where  vomiting  occurs  or  where  the  stomach  has 
been  washed  out;  in  cases  of  absorption  of  alkaline  effu- 
sions ;  after  the  use  of  alkaline  waters  and  medicines. 

The  alkaline  reaction  of  the  urine  from  the  presence  of  a 
volatile  alkali  is  produced  by  the  development  of  bacteria 
in  the  urine,  wdiich  decompose  the  urea  into  ammonium  car- 
bonate, thus  (CONHa),  4-  2  H,0  =  C0(NH40)<,.  This  decom- 
position takes  place  in  all  urine  that  has  stood  for  a  long 


VIII  THE    EXAMINATION   OF   THE    URINE  185 

time,  especially  in  a  warm  place.  Should  the  urine  be 
decomposed  as  soon  as  it  is  voided  from  the  bladder,  there 
is  a  cystitis  present. 

Ammoniacal  decomposition  produces  a  very  characteristic 
odor,  which  is  easily  recognized. 

Every  alkaline  urine  contains  a  sediment  composed  of 
ammonio-magnesium  j^hosphates  (triple  phosphates),  cal- 
cium phosx^hate,  and  often  of  calcium  carbonate.  In  decom- 
position the  triple  phosphates  are  most  prominent,  and  at 
the  same  time  the  urine  is  rich  in  bacteria.  When  the 
alkalinity  is  due  to  a  fixed  alkali,  the  sediment  contains 
much  calcium  phosphate  and  calcium  carbonate. 

The  Chemical  Examination  of  the  Pathological 
Elements  or  the  Urine 

Albumin.  — The  presence  of  albumin  (serum  albumin  and 
serum  globulin)  in  the  urine  indicates  a  lesion  of  the  renal 
epithelium.  Under  this  head  it  may  deal  with  mild  or 
intense  disturbances  of  nutrition  (a  congestion,  an  ansemia, 
cloudy  swelling,  fatty  metamorphosis).  Pronounced  persist- 
ent albuminuria  indicates  nephritis. 

In  all  urine  of  human  beings  nominal  traces  of  albumin  may 
be  found,  still  these  can  only  be  detected  by  especially  fine  meth- 
ods of  analysis  (normal  alhuminurid).  Small  quantities  of  albumin 
appear  in  some  persons  as  a  transient  constituent  of  the  urine  after 
a  meal  rich  in  albuminoids,  after  intense  physical  strains,  after  hot 
baths,  and  after  psychical  excitement.  It  is  then  known  as  physio- 
loyical  albuminuria. 

If  the  urine  contain  blood  or  pus,  the  albumin  derived  from 
their  plasma  is  dissolved  by  the  urine  and  even  after  filtration  the 
urine  will  show  the  reaction  for  albumin ;  such  an  albuminuria 
does  not  denote  in  itself  a  disease  of  the  kidneys.  It  is  known  as 
spurious  albuminuria. 

The  examination  of  a  patient  is  incomplete  without  an 
examination  of  the  mine  for  albumin.    "When  a  small  c^uan- 


186  THE   EXAMINATION   OF   THE   URINE  chap. 

tity  is  detected,  the  urine  should  be  again  examined  from 
specimens  passed  at  different  periods  of  the  day  (the  urine 
passed  on  awakening  in  the  morning  is  often  free  from 
albumin  even  when  the  kidneys  are  diseased). 

Of  practical  significance  is  intermittent  alhuminurin,  which  is  the 
condition  obtaining  when  small  quantities  of  albumin  appear 
transiently  in  the  urine  at  different  times  and  mostly  in  otherwise 
healthy  young  persons.  Even  if  the  suspicion  of  nephritis  must 
be  entertained,  the  progress  of  the  disorder  is  most  favorable. 
Cyclical  albuminuria  occupies  a  peculiar  position ;  it  consists  in 
this  :  the  urine  in  the  early  morning  is  always  free  of  albumin,  but 
shows,  if  examined  every  two  hours,  varpng  amounts  of  albumin, 
which  reach  the  maximum  mostly  at  night.  Though  in  these 
cases  the  question  of  a  chronic  nephritis  can  not  be  excluded  with 
absolute  certainty,  still  a  more  frequent  disappearance  of  albumin 
is  observed. 

Tests  for  Albumin 

Freshly  voided  urine  should  be  used  and  preferably  the  last 
portion  of  the  urine  which  has  been  passed. 

For  the  preparation  of  the  tests  the  urine  should  be  clear,  it 
should  h&ßltered. 

1.  The  boiling  test.  The  urine  is  placed  in  a  test-tube  to  one- 
quarter  of  its  length  and  is  then  heated  in  the  flame  until  it  boils, 
when  y^ö  volume  of  nitric  acid  is  added.  Should  the  urine  have 
become  cloudy  and  the  cloud  have  become  cleared  up  during  the 
lieating,  the  cloudiness  was  due  to  the  presence  of  acid  sodium 
urate.  Should  the  cloudiness  exist  on  heating  and  become  dis- 
pelled only  after  the  addition  of  nitric  acid,  it  was  due  to  the 
presence  of  either  calcium  carbonate  or  calcium  phosphate.  Per- 
sistency of  the  cloudiness  or  the  appearance  of  a  precipitate  after 
the  addition  of  the  nitric  acid  indicates  albumin. 

Should  the  portion  tested  in  this  manner  be  permitted  to  stand 
in  the  test-tube  over  night,  the  precipitate  will  have  gravitated 
to  the  bottom  of  the  tube.  The  volume  of  the  precipitate  in  its 
relation  to  the  volume  of  the  original  fluid  tested  will  give  an 
approximate  quantitative  test.  This  relation  is  as  follows :  slight 
cloudiness  of  the  fluid  (trace  of  albumin)  corresponds  to  0.01  per 
cent. ;  when  the  precipitate  occupies  merely  the  bottom  of  the 
tube,  there  is  0.05  per  cent,  of  albumin  ;  when  the  precipitate  is 


viil  THE   EXAMINATION   OF  THE   URINE  187 

j\^  of  the  volume  of  the  tube  contents,  there  is  0.1  per  cent,  of 
albumin;  when  \  of  the  volume,  0.25  per  cent.;  I  of  the  volume, 
0.5  per  cent. ;  ^  of  the  volume,  1  per  cent. ;  when  the  whole  contents 
become  solid,  between  2  and  3  per  cent,  are  present. 

2.  Test  with  acetic  acid  and  potassiiDii  ferroci/tinide.  To  the 
cold  urine  in  a  test-tube  a  few  drops  of  acetic  acid,i  then  some  of 
a  5  per  cent,  solution  of  potassium  ferrocyanide  is  added  drop  by 
drop;  if  albumin  be  present  there  will  be  immediately  or  in  a  few 
moments  a  flaky  precipitation  of  the  coagulated  albumin. 

3.  Heller's  test.  Concentrated  nitric  acid  is  slowly  added  to  a 
small  (pumtity  of  urine  contained  in  a  test-tube.  The  tube  should 
be  held  inclined  that  the  aoid  may  flow  down  the  wall  of  the  tube. 
The  acid  will  sink  to  the  bottom  and  at  the  dividing  line  between 
acid  and  urine,  if  albumin  be  present,  a  narrow  cloudy  white 
ring  will  be  formed.  Still  a  similar  ring  may  be  produced  in  the 
presence  of  uric  acid,  urea  nitrate,  and  of  the  resinous  acids 
which  result  from  the  administration  of  resinous  substances  like 
turpentine,  copaiba,  etc.  The  ring  formed  from  the  presence  of 
the  resinous  acids  is  soluble  in  alcohol,  that  from  urea  forms  only 
after  long  standing  and  is  also  distinctly  crystalline ;  the  uric  acid 
ring  is  not  as  sharply  defined  as  is  the  ring  arising  from  the  pres- 
ence of  albumin,  it  rises  higher  in  the  urine  and  is  only  produced 
in  very  concentrated  urine. 

Quantitative  determination  of  the  albumin.  For  clinical  purposes 
a  sufficiently  accurate  quantitative  analysis  may  be  made  by 
means  of  EshacJi's  albuminometer.  The  albuminometer  is  filled 
to  the  line  marked  U  with  the  urine  to  be  examined,  the  Esbach 
fluid,  which  consists  of  citric  acid  5,  picronitric  acid  2.5,  dis- 
tilled water  245,  is  then  added  to  the  line  marked  Pi,  the  mixture 
is  then  shaken,  and  on  the  following  day  the  deposit  which  has 
collected  will  reach  a  line  at  the  lower  portion  of  the  tube,  which 
is  graduated,  denoting  in  grammes  the  amount  of  a-lbumin  present 
in  1000  cc.  of  urine. 

For  scientific  purposes,  loeighing  of  the  precipitated  albumin  is 
the  best  method.  Tiiis  method  consists  of  placing  100  cc.  of  urine 
in  a  porcelain  dish,  adding  sufficient  acetic  acid  to  render  the  urine 
slightly  acid,  and  then  heating  the  contents  of  the  dish  to  the  boil- 
ing-point. The  fluid  containing  the  precipitate  is  then  filtered, 
the  filter  having  previously  been  thoroughly  dried  and  weighed. 
The  precipitate  is  well  washed  with  hot  water,  then  with  alcohol 

1  Sometimes  a  cloudiness  develops  on  the  addition  of  the  acetic  acid ; 
this  is  due  to  mucin  or  nucleo-albumin,  and  should  be  removed  by  filtration. 


188  THE   EXAMINATION   OF   THE   URINE  chap. 

and  ether;  it  is  dried  and  weighed;  the  additional  weight  will 
represent  the  percentage  amount  of  albumin. 

In  addition  to  the  albumin  precipitated  by  boiling,  the 
urine  may  contain  forms  of  albumin  which  are  not  precipi- 
tated by  heat.  These  forms  also  result  in  gastric  digestion 
of  albumin.  It  has  recently  been  proven  that  the  end 
product  of  the  gastric  digestion  of  albumin  {Killine's  pep- 
tone) does  not  appear  in  the  urine,  but  that  only  premature 
stages  of  the  same  (albumoses  and  propeptones)  are  there 
found.  It  is  a  mistake,  therefore,  to  speak  of  a  peptonuria ; 
we  ought  to  call  that  condition  albumosuria.  However,  this 
term  has  up  to  this  time  been  very  little  used. 

The  albumoses  (peptone  in  the  old  sense)  are  not  precipi- 
tated by  heat  and  by  acids ;  their  presence  is  determined  by 
the  biuret  test  after  the  other  albuminous  bodies  have  been 
precipitated  and  removed  by  filtration. 

The  albumoses  are  found  in  urine,  especially  in  cases 
of  absorption  of  purulent  or  fibrinous  exudations  (pyogenic 
albumosuria),  especially  in  cases  of  pneumonia  shortly 
before  and  after  the  crisis,  in  purulent  meningitis,  in 
peritonitis,  in  empyema,  at  times  in  cases  of  intestinal 
ulceration,  in  many  diseases  of  the  liver,  in  puerperal 
fever  (enterogenous ,  hepatogenous,  and  x>uerpjeral  albumosu- 
ria). Albumosuria  is  chiefly  diagnostic  of  suppuration,  but 
should  be  estimated  only  wdth  great  precaution. 

Test  for  peptone  (Hofmeister  s  test).  Add  to  500  cc.  of  urine  50  cc. 
of  a  concentrated  solution  of  sodium  acetate;  di'op  slowly  into  this 
a  concentrated  solution  of  ferric  chloride,  until  the  resulting  fluid 
remains  at  a  red  color.  At  this  stage  carefully  add  a  solution  of 
potassium  hydrate,  until  the  previously  strongly  acid  mixture  be- 
comes neutral,  or  is  only  slightly  acid;  then  boil  and  filter  after 
the  fluid  becomes  cool.  Should  the  filtered  solution  be  found  by 
the  acetic  acid  and  potassium  ferrocyanide  test  to  be  free  from 
albumin,  the  biuret  test  is  then  used :  a  few  drops  of  potassium 
hydrate  and  a  few  of  a  1  per  cent,  solution  of  cupric  sulphate  being 
added,  a  beautiful  red  color  results  if  peptone  be  present. 


VIII  THE   EXAMINATION   OF   THE   URINE  189 

The  recently  proposed  method  of  Salkoivski  is  much  simpler  and 
just  as  sensitive:  20  to  50  cc.  of  urine  which  has  been  freed  from 
albumin,  and  to  which  some  hydrochloric  acid  has  been  added,  is 
precipitated  by  phospho-molybdic  acid ;  the  precipitate  is  heated, 
washed  with  water,  finally  dissolved  in  a  weak  solution  of  sodium 
hydrate,  and  again  heated  until  it  assumes  a  yellow  color.  After 
cooling,  the  biuret  test  is  put  into  use  (see  above). 

Blood.  —  We  recognize  the  presence  of  blood  by  the  color 
of  the  urine.  This  is  bright  red  with  a  greenish  shimmer 
(like  meat  solution)  in  the  presence  of  oxyhcemoglobin  ;  dirty 
brownish-red  in  the  presence  of  methmmoglohin.  Neverthe- 
less, w^e  ought  not  decide  that  blood  is  present  from  the 
color  alone;  a  microscopical  examination  of  the  sediment 
(see  p.  210)  and  the  chemical  tests  for  blood  should  also  be 
made.  A  spectroscopic  examination  is  only  seldom  used 
(Chap.  XI.). 

Helleres  test.  To  the  urine  in  a  test-tube  \  of  its  volume 
of  potassium  hydrate  solution  is  added,  and  the  mixture  is 
boiled.  After  a  short  time  the  earthy  phosphates  precipi- 
tate (magnesium  and  calcium  phosphates).  When  blood  is 
present  the  flaky  precipitates  will  be  of  a  reddish-brown 
color  (in  normal  urine  they  are  grayish- white).  The  color 
is  best  determined  after  the  precipitate  has  fully  collected 
together. 

Van  Deen's  test  (guaiac  test).  Add  to  the  urine  2  cc.  of 
tincture  of  guaiac  and  2  cc.  of  old  oil  of  turpentine,  then 
shake  the  mixture  thoroughly ;  if  blood  be  present,  the 
whole  solution  will  become  blue  in  a  short  time  (pus  will 
give  the  same  reaction).  Instead  of  old  turpentine  oil  the 
following  mixture  may  be  used  (HuhnerfekV s  test) :  glacial 
acetic  acid,  2 ;  distilled  water,  2 ;  oil  of  turpentine,  100 ; 
absolute  alcohol,  100 ;    chloroform,  100. 

Blood  in  the  urine  signifies  a  hmmaturia  or  a  hannoglo- 
bimtria.  Hmmaturia  indicates  the  presence  of  the  red  blood 
corpuscles  in  the  urine ;  the  blood  may  come  from  the  kidney, 


190  THE   EXAMINATION   OF   THE   URINE  chaj*. 

the  pelvis  of  the  kidney,  the  bladder,  or  the  urethra.  The 
causes  of  hematuria  are  acute  nephritis,  renal  calculi, 
haemorrhagic  infarct  of  the  kidneys,  tumors  of  the  kidneys, 
renal  hsemophilia,  pyelonephritis,  acute  cystitis,  carcinoma 
of  the  bladder,  aiid  stone  in  the  bladder. 

Temporary  hsematuria  may  also  be  the  result  of  physical 
over-exertion. 

In  making  a  differential  diagnosis  the  following  data 
should  be  considered :  the  urine  is  small  in  amount  in  acute 
nephritis  and  contains  more  albumin  than  the  amount  of 
blood  it  contains  would  justify ;  in  addition  to  these  facts 
there  are  casts  in  the  deposits,  and  the  patient,  as  a  rule, 
has  dropsy.  Haemorrhagic  renal  infarction  is  associated 
with  cardiac  disease,  and  is  accompanied  by  fever  and 
pains,  the  blood  disappearing  from  the  urine  in  a  few  days. 
The  haemorrhage  from  renal  calculi  is  preceded  by  attacks  of 
colic,  and  the  calculus  may  be  passed  with  the  urine.  In 
pyelonephritis  a  purulent  deposit  will  also  be  present  in  the 
urine.  In  cystitis  there  is  pain  in  the  bladder  and  vesicular 
tenesmus,  while  the  urine  contains  pus  at  the  same  time. 
In  cases  of  tumor  it  is  sometimes  possible  to  find  small 
particles  of  the  growth  in  the  urine. 

AVhen  a  careful  consideration  of  all  the  causes  mentioned 
fails  to  discover  the  origin  of  the  hsematuria,  it  may  be  pos- 
sible that,  as  occurs  in  rare  instances,  the  haemorrhage  arises 
from  a  healthy  kidney,  of  which  two  varieties  are  known. 

1.  The  hcematuria  of  bleeders  (renal  haemophilia)  may  be 
diagnosticated  when  the  patient's  family  is  one  of  bleeders, 
and  when  he  himself  has  given  previous  evidence  of  haemo- 
philiac dyscrasia.  2.  Angioneurotic  hcematuria,  which  oc- 
curs in  neuropathic  individuals ;  in  which  case  one  may 
succeed  in  stopping  the  haemorrhage  by  suggestion  or  hydri- 
atic  measures.  Haemorrhage  from  a  normal  kidney  shoukl 
only  be  considered  when  every  other  diagnostic  possibility 
has  been  excluded. 


VIII  THE   EXAMINATION  OF  THE   URINE  191 

In  doubtful  cases,  severe  pain  in  the  lumbar  region  may 
indicate  the  origin  of  blood  as  coming  from  the  kidney ; 
proof  of  this  is  the  j^resence  of  red  blood  corpuscles  in  the 
urinary  sediment,  when  they  occur  as  blood  casts. 

We  can  occasionally  determine  whether  the  haemorrhage  comes 
from  the  bladder  b}^  catheterizing  and  washing  out  the  bladder 
after  urination  has  occurred.  If  the  blood  comes  from  the  bladder, 
the  returning  water  will  be  blood-stained.  In  spite  of  this  aid  it 
is  at  times  extremely  ditficult  to  determine  whether  the  source  of 
the  blood  is  from  the  kidney  or  bladder.  In  such  cases  the  source 
of  the  bleeding  may  be  determined  by  the  cystoscope  in  expert 
hands.  The  cystoscope  will  also  determine  from  which  kidney 
the  blood  arises. 

Hmmoglohinuria  is  the  appearance  of  a  solution  of  the 
coloring  matter  (ivithout  the  corpuscles)  of  the  blood  in  the 
urine.  It  results  in  consequence  of  the  red  blood  corpuscles 
being  dissolved  from  various  causes,  namely,  from  poisons 
(potassium  chlorate,  mussel  poisoning,  etc.) ;  it  appears  after 
transfusion  of  blood,  it  results  from  burns  and  as  a  specific  dis- 
ease (periodical  hsemoglobinuria),  and  often  after  exposure. 

Biliary  coloring  matter  appears  in  the  urine  either  reduced 
as  hydrobiliruhin,  the  same  as  urobilin,  or  unreduced  in  the 
form  of  bilirubin.  The  special  biliary  coloring  matter  is 
detected  by  the  beer-browm  color  of  the  urine  and  the  yellow 
color  of  the  foam  which  is  produced  by  shaking.  Urine 
containing  urobilin  is  yellowish-red  with  a  tinge  of  orange. 
For  a  ]DOsitive  determination  special  chemical  and  spectro- 
scopic analyses  are  required. 

Gmeliii's  test  for  bilirubin.  Concentrated  hydrochloric  acid  is 
mixed  in  a  test-tube  w^ith  one  or  tw^o  drops  of  fuming  nitric  acid. 
The  urine  is  then  carefully  poured  dow'U  the  w^alls  of  the  tube ;  the 
acid  and  the  urine  form  two  distinct  layers,  and  at  their  junction 
a  colored  ring  will  be  formed ;  this  ring  is  first  green  (biliverdin), 
then  violet,  then  red,  then  yellow  (choleteli)i),  and  finally  it  assumes 
a  dirty  color.  The  production  of  a  blue  ring  arises  from  the  pres- 
ence of  indican. 


192  THE   EXAMINATION  OF   THE   URINE  chap. 

The  same  diagnostic  conclusions  should  be  formed  when 
bilirubin  is  shown  to  be  present  in  the  urine  as  would  from 
the  presence  of  icterus. 

Test  for  urobilin.  Render  the  urine  alkaline  by  adding  some 
ammonia  to  the  urine  in  a  test-tube,  then  add  8-10  drops  of  a 
10  per  cent,  solution  of  zinc  chlorate  and  filter  quickly.  View  the 
filtered  solution  against  a  dark  background,  when  it  will  appear 
green,  but  by  transmitted  light  it  will  be  rose-red.  Spectroscopical 
examination  of  the  urine  will  detect  the  smallest  portion  by  show- 
ing an  absorption  line  between  the  green  and  blue  fields. 

Hydrobilirubin  (urobilin)  occurs  in  many  cases  of  icterus 
in  which  the  color  of  the  skin  of  the  patient  is  a  dirty  yel- 
low (urobilin  icterus),  in  states  of  passive  congestion,  and  in 
high  fever.  In  addition  it  occurs  where  large  extravasa- 
tions of  blood  have  been  absorbed  (as  a  result  of  the  reduc- 
tion of  the  coloring  matter  of  the  blood  identical  with 
bilirubin).  With  a  sufficient  regard  for  the  other  causes  a 
diagnosis  of  internal  haemorrhage  (apoplexy,  infarct,  etc.) 
may  be  justified  from  the  presence  of  a  large  amount  of 
urobilin  in  the  urine. 

Sugar.  —  Urine  which  contains  sugar  is  usually  passed  in 
large  amounts ;  it  is  of  light  color,  and  of  a  high  specific 
gravity. 

The  proof  of  sugar  in  the  urine  depends  upon  its  follow- 
ing characters :  — 

1.  Glucose  is  colored  brown  (caramel  formation)  when 

boiled  with  potassium  hydrate. 

2.  Glucose  has  the  x^roperty  to  reduce  other  bodies  under 

high  temperatures. 

3.  Glucose  ferments  in  the  presence  of  yeast  and  is  con- 

verted into   alcohol  and  carbonic  acid  (CgHiaOe  = 
2C2H50H-f2C02). 

4.  Glucose  turns  the  plane  of  polarized  light  to  the  right. 

5.  Glucose  unites  with  phenyl  hydrazin  into  a  characteris- 

tic chemical  compound  (glucosazon). 


VIII  THE   EXAMINATION   OF   THE   URINE  193 

Qualitative  Analysis  for  Sugar 

1.  Moore  s  test  consists  in  adding  to  the  urine  in  a  test-tube  I  of 
its  volume  of  potassium  hydrate  solution  and  boiling  the  mixture 
several  times  in  succession;  in  the  presence  of  sugar  (glucose)  the 
urine  will  assume  a  brown  color. 

2.  Reduction  tests,  a.  Trommer's  test  consists  in  adding  to  the 
urine  \  of  its  volume  of  potassium  hydrate  solution  and  again 
adding  enough  of  a  10  per  cent,  solution  of  cupric  sulphate  until 
the  blue  precipitate  which  is  formed  thereby  is  entirely  dissolved 
while  agitating  the  mixture  ;  as  soon  as  the  addition  of  another 
drop  of  the  copper  solution  is  precipitated  and  is  not  dissolved  by 
agitating  the  contents  of  the  tube,  stop  the  addition  of  the  cupric 
sulphate  and  heat  carefully  the  upper  part  of  the  solution  in  the 
tube  by  holding  that  part  of  the  tube  over  a  flame.  If  sugar  be 
present,  a  yellowish-red  precipitate  will  be  formed  as  soon  as  that 
part  of  the  mixture  rises  to  60"^  to  70"^  C.  before  the  boiling-point  is 
reached.     As  soon  as  the  precipitate  forms,  stop  the  heating. 

The  reaction  proceeds  as  follows  :  CUSO4  +  2  KHO  =  Cu  (HO)« 
(cupric  hydroxide)  -|-  K2SO4.  Cupric  hydroxide,  Cu(HO)o,  in  itself 
may  be  converted  by  heat  into  black  cupric  oxide,  (CuO)+  H2O. 
The  2  CuO,  or  the  Cu(0H)2,  gives  up  by  the  heat  one  atom  of  O  to 
the  sugar,  thus  producing  Cu^O,  yellow  copper  oxydul  (cupro-oxyd), 
or  CuOH,  brown  copper  oxydulhydrate  (cuprohydoxyd)  respec- 
tively. 

The  ordinary  dissolving  of  the  cupric  hydroxide  with  the  pro- 
duction of  an  a2wre-blue  color  does  not  determine  the  presence  of 
sugar;  for  the  same  reaction  may  be  produced  when  albumin,  am- 
monia, and  other  organic  substances  are  present. 

Even  the  change  of  color  of  the  tested  solution  to  yellow  without 
the  precipitation  of  a  yellow  precipitate  does  not  prove  the  exist- 
ence of  sugar ;  for  uric  acid  and  kreatinin  will  likewise  reduce  the 
oxide  of  copper,  but  retain  copper  oxydul  (cupro-oxyd)  in  solution. 

In  the  strict  acceptation  the  production  of  copper  oxydul  does 
not  prove  the  existence  of  sugar,  but  oiily  that  a  reducing  substance 
is  present  in  the  urine.  Other  reducing  substances  may  occur  in 
the  urine  especially  after  the  ingestion  of  certain  substances  (chlo- 
ral hydrate,  camphor,  chloroform,  turpentine,  benzoic  acid,  salicy- 
lic acid,  copaiba  and  cubebs).  When  any  of  these  have  been 
taken,  in  addition  to  Trommer s  test,  a  control  analysis  for  sugar 
should  be  made  by  fermentation  and  the  polariscope. 

Trommer's  test  may  be  made  more  quickly  by  adding  slowly  an 
o 


194  THE   EXAMINATION   OF   THE   URINE  chap. 

equal  volume  of  a  doubly  diluted  Fehling's  solution  to  a  few  cubic 
centimetres  of  the  boiling  urine.  If  sugar  be  present,  a  yellow  pre- 
cipitate will  be  thrown  down.  The  Fehling's  solution,  however, 
should  be  previously  tested  to  see  if  it  itself  will  not  form  a  similar 
precipitate  on  boiling. 

b.  Böttchers  test.  Saturate  10  cc.  of  urine  with  some  finely 
powdered  sodium  carbonate,  add  thereto  a  very  small  quantity  of 
basic  bismuth  nitrate,  and  boil  for  some  minutes.  The  production  of  a 
black  color  in  the  urine  indicates  the  presence  of  sugar;  only  when 
organic  substances  (albumin,  mucus,  pus,  and  blood)  are  present  in 
the  urine  may  this  production  of  bismuth  sulphide  lead  to  error. 
A  very  convenient  method  for  conducting  this  test  is  by  the  use 
of  Nylander's  solution,  which  consists  of  Rochelle  salts  (potassium 
sodium  nitrate,  4;  10  per  cent,  solution  of  sodium  hydrate,  100; 
bismuth  subnitrate,  2 ;  heated  together  and  then  filtered).  If 
urine  to  which  j\,  of  its  volume  of  Nylander's  solution  has  been 
added  be  boiled,  should  sugar  be  present  a  brown  or  black  color 
will  be  produced. 

c.  Ruhner's  test.  Add  to  the  urine  a  knife  tip  full  of  plumbic 
acetate ;  a  precipitate  of  plumbic  phosphate  and  plumbic  sulphate 
will  be  formed.  Remove  the  precipitate  by  filtering  and  to  the 
filtered  solution  add  some  ammonia,  whereupon  a  white  precipitate 
of  plumbic  oxide  will  be  formed.  On  boiling  at  this  point  of  the 
procedure  the  white  precipitate  will  become  rose-red  in  the  pres- 
ence of  sugar,  owing  to  the  formation  of  a  higher  oxide  (red  oxide 
of  lead,  Pb304). 

3.  Fermentation  test.  This  test  is  one  of  the  most  reliable  of  all 
tests  for  sugar.  It  is  performed  as  follows:  shake  the  test-tube 
containing  the  urine  to  which  a  small  cube  of  fresh  compressd 
yeast  has  been  added,  then  pour  this  mixture  into  a  fermentation 
tube;  turn  the  tube  so  that  the  long  arm  will  be  filled  completely 
by  the  urine.  When  the  apparatus  has  been  filled,  pour  some 
mercury  into  it  in  order  to  close  the  long  arm,  tiien  place  the 
entire  apparatus  in  a  warm  place  at  about  24° C.  Should  the  urine 
contain  sugar,  gas  bubbles  composed  of  CO2  will  arise  in  the  tube 
in  a  few  hours.  That  this  gas  is  truly  CO2  may  be  proven  by  the 
addition  of  potassium  hydrate,  which  will  quickly  absorb  the  gas, 
For  a  control  of  this  test,  two  more  fermentation  tubes  should  be 
prepared,  one  with  a  mixture  of  a  solution  of  glucose  and  yeast  (to 
determine  that  the  yeast  is  efficient),  the  other  with  normal  urine 
and  yeast  (this  should  not  generate  gas,  and  should  show  that  the 
yeast  itself  is  free  from  sugar). 


VIII 


THE   EXAMINATION  OF   THE   URINE 


195 


A  fermentation  tube  may  be  improvised  from  a  test-tube,  as  may 
be  seen  from  Fig.  34.  The  picture  shows  a  fermentation  tube 
made  after  Moritz' s  suggestion  and  needs  no  further  explanation. 
Pavy's  fermentation  tube  may  be  prepared  by  introducing  a  glass 
tube  through  the  stopper  of  a  test-tube 
which  has  been  completely  filled  with  the 
urine  to  be  examined  ;  the  tube  should 
reach  almost  to  the  bottom  of  the  test- 
tube.  The  outer  end  of  the  tube  should 
be  bent  and  placed  in  a  vessel  containing 
water ;  the  gas  which  forms  collects  under 
the  stopper,  and  by  pressure  the  urine  rises 
in  the  tube  to  escape  into  the  vessel  con- 
taining the  water. 

4.  Phenyl  hydrazin  test  is  carried  out  as 
follows  :  to  10  cc.  of  a  heated  10  per  cent, 
solution  of  sodium  acetate,  as  much  acid 
phenyl  hydrazin  is  added  as  will  go  on 
the  end  of  a  knife  ;  to  this  mixture  10  cc. 
of  urine  are  added,  and  the  test-tube  con- 
taining the  entire  solution  is  placed  in  a 
water  bath  at  100°  C.  for  an  hour.  When 
sugar  is  present,  numerous  yellow  crys- 
tals of  phenyl  glucosazon  are  formed  and 
precipitated.  The  latter  compound  melts  at  a  temperature  of  205°  C. 
Should  the  urine  contain  but  little  sugar,  the  solution  is  centrifuged, 
and  the  sediment  examined  microscopically  for  the  crystals. 

Sugar  may  appear  in  the  nrine  in  health  after  the  inges- 
tion of  any  meal  containing  more  than  150  g.  of  glucose 
(alimentary  or  physiological  glycosuria).  In  general  a  sus- 
picion of  a  diabetic  tendency  should  be  held  in  every  case 
of  glycosuria,  even  when  sugar  in  the  urine  is  transient  and 
only  small  in  amount. 

Alimentary  glycosuria  has  sometimes  been  observed  after 
the  ingestion  of  moderate  amounts  of  glucose  (about  100  g.) 
in  the  obese,  in  drunkards,  in  cases  o*f  Basedoics  disease,  as 
well  as  in  traumatic  neurosis,  and  also  in  those  who  have 
used  thyreoid  preparations.  In  excessive  diuresis  a  small 
quantity  of  sugar  may  appear  in  the  urine. 


Fig.  34.  —  Lmprotised  Fee- 

iIE>'TATIO>'        ApPAEATCS. 

(Mobitz.) 


196  THE   EXAMINATION   OF   THE    URINE  chap. 

The  persistent  or  long-continued  appearance  of  more  than 
i  per  cent,  of  sugar  in  the  urine  occurs  only  in  diabetes  mel- 
litus. A  complete  diagnosis  of  this  disease  demands  the 
quantitative  determination  of  the  amount  of  sugar  passed 
(see  Chap.  X.,  Diseases  of  Metabolism). 

Quantitative  Analysis  of  Sugar  in  the  Urine 

Estimation  of  the  amount  of  sugar  by  Moore^s  test.  Urine 
heated  with  potassium  hydrate  is  of  a  straw-yellow  color 
when  it  contains  about  1  per  cent,  of  sugar,  amber-yellow 
with  2  per  cent.,  brown,  like  Jamaica  rum,  with  o  per  cent., 
and  dark  broAvn  with  7  per  cent.  This  estimation  is  but 
little  reliable,  and  will  give  to  the  one  who  is  expert  in  its 
use  only  approximate  results. 

Estimation  of  the  amount  with  Fehling^s  solution.  Fehling^s 
solution  consists  of  34.639  g.  of  crystallized  cupric  sulphate, 
173  of  Eochelle  salts,  100  c.c.  of  officinal  sodium  hydrate 
solution,  and  water  to  make  the  entire  mixture  1000  c.c. ; 
1  c.c.  of  this  solution  is  reduced  by  5  mg.  of  glucose. 

Two  cubic  centimetres  of  Fehling^s  solution  are  put  into  a 
test-tube  containing  20  c.c.  of  water,  by  means  of  a  pipette. 
The  cupric  oxide  contained  in  this  amount  is  reduced  by 
exactly  1  eg.  of  sugar.  Bring  the  contents  of  the  test-tube 
to  a  boil ;  then  add  drop  by  drop  the  urine  to  be  examined, 
and  see  by  transmitted  light  after  every  drop  whether  the 
solution  has  become  decolorized.  As  soon  as  it  has,  stop 
adding  the  urine.  The  number  of  drops  of  urine  which 
have  been  added  to  produce  decolorization  will  then  have 
contained  0.01  g.  of  sugar.  Twenty  drops  are  regarded  as 
equal  to  1  c.c.  of  urine. 

The  following  tablö  gives  the  approximate  relation  of 
drops  to  percentage  of  sugar. 


VIII 


THE   EXAMINATION   OF   THE    URINE 


197 


3rop8 

Percentage 

Drops 

Percentage 

100 

0.20 

14 

1.40 

90 

0.21 

13 

1.50 

80 

0.25 

12 

1.60 

70 

0.28 

11 

1.80 

60 

0.30 

10 

2.00 

50 

0.40 

9 

2.20 

40 

0.50 

8 

2.50 

30) 
25  i 

0.60 

7 
6 

2.80 
3.30 

20 

1.00 

5 

4.00 

19 

1.05 

4 

5.00 

18 

1.10 

3 

6.60 

17 

1.15 

2 

10.00 

16 

1.20 

1 

20.00 

15 

1.30 

The  results  of  these  vahies  are  pretty  reliable  when  the 
method  is  properly  used. 

Titration  ivith  the  use  of  Fehling's  solution.  Strongly  dilute 
20  CO.  of  Feliling^s  solution  in  a  porcelain  dish ;  dilute  the 
urine  ten  times  and  place  it  in  a  graduated  burette.  Drop 
the  urine  slowly  into  the  boiling  Fehling^s  solution  until  all 
the  copper  has  been  precipitated  and  the  solution  has  be- 
come entirely  decolorized.  The  amount  of  sugar  in  the 
urine  necessary  to  perform  this  reduction  is  0.1  g. ;  hence 
the  amount  of  urine  used  contains  0.1  g.  of  sugar.  From 
this  the  percentage  of  sugar  is  easily  reckoned.  For  in- 
stance, if  27  c.c.  of  the  ten  times  diluted  urine  were  used  to 
reduce  20  c.c.  of  Fehling's  solution,  then  0.1  g.  of  sugar  was 
contained  in  the  27  c.c.  of  the  ten  times  diluted  urine ;  there- 
fore in  100  c.c.  of  the  same  dilution  of  urine  there  would  be 

— — =  0.37;  but  since  the  urine  Avas  diluted  ten  times, 

27 

the  total  percentage  would  be  10  x  0.37  =  3.7  i)er  cent.     In 

order  to  accurately  judge  the  time' to  stop  adding  the  urine, 

a  small  amount  of  the  Feliliiufs  solution  that  has  been  used 

is  filtered  and  added  to  some  potassium  ferrocyanide  solu- 


198  THE   EXAMINATION   OF   THE   URINE  chap. 

tion  ;  should  some  unreduced  copper  be  still  held  in  the 
solution,  a  brown  color  (cupric  ferrocyanide)  will  be  pro- 
duced. The  titration  method  is  entirely  accurate,  but  may 
lead  to  error  on  account  of  the  other  reducing  substances 
(see  p.  193)  contained  in  the  urine. 

Estimation  by  Einhornes  saccharimeter.  This  instrument 
is  the  ordinary  fermentation  tube,  whose  long  arm  is  empir- 
ically graduated.  10  c.c.  of  urine  are  mixed  in  a  test-tube 
with  a  piece  of  compressed  yeast  about  the  size  of  a  bean ; 
the  mixture  is  well  shaken  and  poured  into  the  fermentation 
tube.  According  to  its  specific  gravity,  the  urine  should  be 
previously  diluted ;  a  specific  gravity  of  1018  to  1022  neces- 
sitates a  double  dilution,  1022  to  1028  a  fivefold  dilution, 
1028  to  1038  a  tenfold  dilution.  This  method  gives  a 
pretty  good  result  for  urine  containing  less  than  1  per  cent, 
of  sugar,  but  it  is  not  always  accurate  in  estimating  the 
percentage  of  sugar  in  urine  containing  more  than  1  per 
cent.  However,  it  is  quite  serviceable  for  practical  pur- 
poses, especially  for  continued  estimations. 

Determination  of  the  sj^ecißc  gravity  before  and  after  fer- 
mentation. The  temperature  and  the  specific  gravity  of  the 
urine  are  taken ;  then  100  to  200  c.c.  of  urine  are  placed  in 
a  flask  containing  some  compressed  yeast,  and  the  mixture 
is  allowed  to  stand  at  24°  C.  After  24  hours,  when  the 
formation  of  gas  has  ceased,  the  mixture  is  filtered,  cooled  to 
the  original  temperature,  and  the  specific  gravity  is  then 
taken.     (The  urinometer  should  be  standardized.) 

Every  degree  less  in  specific  gravity  will  indicate  0.23 
per  cent,  of  sugar,  so  that,  if  the  specific  gravity  of  the 
urine  was  originally  1032,  and  after  fermentation  1022,  the 
amount  of  sugar  contained  would  be  10  x  0.23  =  2.3  per  cent. 

Tliis  method  gives  very  accurate  restdts  when  the  amount 
of  sugar  in  the  urine  is  over  0.5  per  cent. 

Estimation  by  polarization.  20  to  30  c.c.  of  urine  are 
placed  in  a  glass  beaker,  and  a  small  quantity  of  powdered 


VIII  THE   EXAMINATION   OF   THE   URINE  199 

plumbic  acetate  is  added;  the  resulting  precipitate  is  then 
removed  by  filtration.  The  filtered  solution  is  then  placed 
in  the  glass  tube  of  the  polariscope  (usually  will  contain  10 
or  20  c.c.  of  fluid),  special  care  being  taken  to  free  the  tube 
of  all  air-bubbles.  The  interior  of  the  tube  should  first  be 
washed  with  some  of  the  filtered  mixture.  From  the  scale 
attached  to  the  polariscope,  better  from  the  average  of  three 
different  readings  of  the  scale,  the  percentage  of  sugar  is 
determined  in  this  way.  The  deviation  to  which  the  tube 
is  directed  is  read  off  from  the  scale  as  degrees ;  this  num- 
ber is  multiplied  by  100,  and  the  result  divided  by  53.1.  If 
the  tube  of  the  polariscope  is  20  cm.  long,  the  quotient  is 
divided  by  2.  (The  description  and  theory  of  the  polari- 
scope may  be  found  in  the  larger  text-books.)  Should 
the  urine  contain  alhumin,  it  should  be  precipitated  before  the 
polariscope  is  used,  because  albumin  deviates  light  to  the 
left. 

The  polarization  of  urine  will  give  other  results  from  the 
titration  method:  (1)  if  the  urine  contains  other  reducing 
substances  besides  sugar ;  (2)  if  it  contains  other  substances 
which  deviate  light  to  the  left,  such  as  oxy butyric  acid, 
which  is  found  in  severe  cases  of  diabetes.  In  such  cases 
it  is  wise  to  titrate  and  to  polarize  again  after  the  proposed 
fermentation.  Excepting  these  sources  of  error,  the  polari- 
zation gives  accurate  results. 

Acetone  and  aceto-acetic  acid.  —  Both  these  compounds  ap- 
pear abundantly  in  the  urine  after  an  extensive  disintegra- 
tion of  the  albuminoids  of  the  body,  especially  in  cases  of 
high  fever,  in  severe  anaemias,  and  in  some  cases  of  carci- 
noma, in  hasty  consumption,  in  severe  forms  of  diabetes, 
and  in  inanition.  In  severe  diabetes  acetonuria  occurs  even 
when  there  has  been  a  total  abstinence  from  the  carbo- 
hydrates, and  when  tissue  disintegration  has  not  occurred. 
In  addition  acetone  is  found  in  the  urine  in  cases  of  disturb- 
ances of  digestion  and  in  intestinal  diseases.     In  the  latter 


200  THE   EXAMINATION   OF   THE   URINE  chap. 

cases  acetone  lias  been  found  even  in  the  contents  of  tlie 
intestine. 

Aceto-acetic  acid  (CHgCOCHgCOOH)  is  tested  by  Gerhardfs 
method  of  reaction  to  ferric  chloride  solution.  On  the  addition  of 
Fe^Clß  to  the  urine,  a  gray  precipitate  of  iron  phosphate  is  thrown 
down  ;  on  the  further  addition  of  the  ferric  chloride,  if  aceto-acetic 
acid  be  present,  a  deep  claret  color  is  produced.  If  the  contents  of 
the  tube  are  now  shaken,  the  resulting  froth  will  have  a  red-violet 
tinge.  On  the  addition  of  sulphuric  acid  the  red  color  will  dis- 
appear. 

On  boiling  the  urine  the  aceto-acetic  acid  will  be  converted  into 
acetone  and  carbonic  acid  :  — 

CH3COCH2COOH  =  CH3COCH3  -h  CO2. 

The  acetone  is  distilled  over  (distil  about  J  litre  of  urine  with  a 
few  drops  of  hydrochloric  acid)  and  may  then  be  tested  by  Liehen'' s 
test,  which  is  conducted  as  follows :  some  of  the  distilled  fluid  is 
mixed  in  a  test-tube  with  a  few  drops  of  a  solution  of  iodine  in 
potassium  iodide  (iodine,  2 ;  potassium  iodide,  10 ;  distilled  water, 
200)  and  of  potassium  hydrate  solution.  Should  acetone  be  present 
in  the  urine,  an  immediate  precipitation  of  yellowish-white  charac- 
teristically smelling  iodoform  will  result. 

Acetone  is  proved  to  exist  in  the  urine  by  means  of  Legal's  test, 
A  few  drops  of  a  sodium  nitro-cyanide  solution  are  added  to  the 
urine  to  be  tested  and  the  mixture  is  then  rendered  strongly  alka- 
line. A  purple-red  color  changing  gradually  to  a  yellow  will 
result ;  2  to  3  drops  of  acetic  acid  are  then  added,  and,  if  acetone 
be  present,  a  color  varying  from  carmine  to  purplish-red  will  form 
where  the  acid  touches  the  solution.  Still,  it  is  doubtful  whether 
acetone  occurs  preformed  in  the  urine. 

The  claret-red  ferric  chloride  reaction  is  of  practical  diag- 
nostic importance,  especially  in  diabetes;  the  long-continued 
presence  of  a  large  amount  of  acetone  indicates  a  grave  form 
of  the  disorder  and  should  suggest  a  very  unfavorable 
prognosis. 

Ehrlich's  diazo-reaction.  —  Tn  many  diseases  there  appear 
in  the  urine  certain  aromatic  com})Oiinds  of  whose  composi- 
tion little  is  known,  which  unite  with  sulqiho-diazohenzol  in 
such  a  manner  as  to  produce  certain  characteristic  colors. 


VIII 


THE   EXAMINATION   OF   THE   URINE 


201 


The  chemical  course  of  the  diazo-reaction :  sulphanilic  acid 
(CpJI^NII.,S()oII),  when  united  with  nitrous  acid  (IINOg),  produces 
sulpho-diazo-benzol  (CgllgNNSO^H  [diazo  =  2  atoms  of  N]).  The 
latter  body  unites  with  n)any  aron)atic  amido-compounds  to  pro- 
duce colors.  Tn  order  to  produce  sulpho-diazo-benzol  in  a  fresh 
state  at  any  moment,  it  is  necessary  to  keep  a  solution  of  sulphani- 
lic acid  in  hydrochloric  acid,  and  when  it  is  needed  to  carry  out 
the  test,  to  add  to  this  solution  a  solution  of  sodium  nitrite,  whereby 
nitrous  acid  is  formed  in  a  free  state  which  from  the  sulphanilic 
acid  produces  sulpho-diazo-benzol. 

Method  of  conductiiig  the  diazo-reaction.  Two  solutions  should 
be  prepared  and  separately  kept,  viz. :  — 


1.    Sulphanilic  acid,  5.0 

Hydrochloric  acid  pure,  50.0 
Distilled  water,  1000.0 


2.    Sodium  nitrite,  0.5 

Distilled  water,  100.0 


In  order  to  carry  out  the  test,  50  c.c.  of  the  sulphanilic  acid  solu- 
tion and  1  c.c.  of  the  sodium  nitrite  solution  are  mixed  in  a  glass 
graduate.  This  mixture  is  added  to  the  urine  which  is  to  be  ex- 
amined, in  the  proportion  of  half  urine  and  half  mixture,  and  to 
these  is  added  an  amount  of  ammonia  equal  to  ^  of  the  volume  of 
the  combined  urine  and  mixture.  The  entire  mixture  is  then 
placed  in  a  test-tube  and  violently  shaken.  If  the  resulting  froth 
should  assume  a  deejJ  red  color,  the  diazo-reaction  is  positively 
demonstrated. 

The  diazo-reaction  is  still  more  beautifully  shown  if  we  use 
para-amido-aceto-phenon  in  the  proportion  of  0.5  to  1000  instead 
of  sulphanilic  acid.  This  constitutes  FriedenwahVs  modification  of 
Ehrliches  reaction. 

The  diazo-reaction  is  obtained  in  the  urine  of  cases  of 
typhoid  fever,  pneumonia,  measles,  miliary  tuberculosis, 
sepsis,  and  in  severe  cases  of  phthisis.  It  is  absent  in  men- 
ingitis. The  principal  value  of  the  diazo-reaction  is  its 
presence  in  cases  of  typhoid  fever,  where  in  doubtful  cases 
it  often  decides  the  diagnosis  and  renders  the  relapsing 
character  of  the  subsequent  fever  positive.  The  disappear- 
ance of  the  reaction  shows  that  the  infection  has  subsided. 
In  phthisis  the  appearance  of  the  reaction  indicates  a  bad 
prognosis. 


202  THE   EXAMINATION   OF  THE   URINE  chap. 

Fat  ill  the  urine  is  recognized  by  the  milk-like  cloudiness 
of  the  entire  urine,  which  disappears  when  some  potassium 
hydrate  solution  is  added  to  it  and  the  mixture  well  shaken 
with  ether.  Fat  is  often  held  in  solution  in  the  urine.  On 
microscopical  examination  numerous  small  fat  globules  may 
be  seen.  Even  on  centrifuging  the  urine  the  fat  may  not 
in  all  cases  be  separated.  This  symptom  is  called  cliyluria; 
it  represents  an  individual  disease,  common  in  the  tropics, 
and  often  produced  by  the  filariasangv.irds  (see  Chap.  XII.). 
Chyluria  is  only  seldom  the  result  of  occlusion  of  the  tho- 
racic duct;  in  many  cases  its  etiology  is  obscure. 

Melanin  is  the  coloring  matter  of  melanotic  carcinoma,  which 
at  times  is  swept  into  the  circulation  and  thus  appears  in  the  urine, 
rendering  the  urine  in  rare  cases  a  dark  black  color.  In  other 
likewise  rare  cases  an  antecedent  stage  {inekoiogen)  of  the  same 
coloring  matter  appears  in  the  urine,  from  which  the  latter  may 
be  precipitated  by  ferric  chloride. 

Sulphuretted  hydrogen  occurs  in  rare  cases  in  the  urine  of  pa- 
tients with  cystitis,  and  is  due  to  the  action  of  certain  bacteria 
which  induce  a  peculiar  urinary  metamorphosis.  H^S  may  be 
recognized  by  its  smell,  like  that  of  rotten  eggs,  or  by  holding  over 
the  urine  some  paper  saturated  with  plumbic  acetate,  which  will 
turn  brow^n  owing  to  the  formation  of  plumbic  sulphide. 

Chemical  Examinatiox  of  the  Normal  Ele3iexts  of 
THE  Urine  which  are  Quax^titatively  Changed  by 
Disease 

1.    Inorganic  Elements 

Chlorides  occur  in  the  urine  chiefly  in  the  shape  of  sodium 
chloride ;  the  normal  amount  depends  upon  the  amount  and 
character  of  food  taken,  but  averages  between  10  to  15  g. 
of  NaCl.  They  are  diminished  in  fever,  especially  in  j^neic- 
monia  and  in  inanition. 

The  test  for  chlorides  is  made  in  this  manner :  a  few  drops  of 
nitric  acid  and  a  few  of  a  10  per  cent,  solution  of  silver  nitrate  are 
added  to  the  urine  ;  a  cheesy  precipitate  will  ordinarily  be  formed, 


viii  THE   EXAMINATION   OF  THE   URINE  203 

but  in  tlie  urine  of  cases  of  pneumonia,  etc.,  there  will  often  be 
only  a  slight  cloudiness.  Exact  quantitative  analysis  is  made  by 
titration. 

Phosphates  occur  in  the  urine  as  potassium  sodium,  calcium  and 
nuignesium  phosphates.  The  quantity  daily  passed  in  the  urine 
varies  according  to  the  food  within  wide  limits,  and  is  about  ß  g. 
The  quantitative  analysis  for  phosphates  is  by  methods  of  titration 
and  has  no  essential  diagnostic  bearing. 

Sulphates  appear  partly  as  potassium  sulphate  (preformed 
sulphuric  acid),  partly  as  phenol,  indoxyl,  and  scatoxyl  com- 
pounds (sulphuric  ether  compounds). 

The  separation  of  these  two  classes  of  compounds  is  performed 
thus :  a  few  drops  of  acetic  acid  and  20  c.c.  of  a  10  per  cent,  solu- 
tion of  barium  chloride  are  added  to  the  sjiecimen  of  urine.  By 
this  means  the  preformed  sulphuric  acid  is  precipitated.  The 
solution  is  then  filtered,  thus  removing  the  precipitate.  In  the 
filtered  solution  the  sulphiu'ic  ether  compounds  will  be  contained 
together  with  the  excess  of  barium  chloride.  On  boiling  the  al- 
tered solution  with  hydrochloric  acid,  the  sulphuric  ether  com- 
pounds are  split  up  into  phenol  and  sulphuric  acid;  the  sulphuric 
acid,  uniting  with  the  remaining  barium  chlorides,  is  precipitated 
as  baiiuni  sulphate. 

The  test  in  itself  for  sulphuric  acid  has  no  diagnostic  im- 
portance; but  the  quantitative  determination  of  the  two 
forms  of  sulphuric  acid  (preformed  acid  and  sulphuric  ether) 
is,  because  it  gives  a  reliable  measure  of  the  intensity  of  in- 
testinal decomposition.  For  this  purpose  the  precipitate  of 
barium  (baryta)  sulphate  should  be  weighed. 

Carbonates  occur  in  solution  in  the  urine  in  essential 
amounts  only  after  the  ingestion  of  fruit,  etc. ;  they  also  are 
combined  with  special  alkalies.  Their  presence  is  deter- 
mined by  the  evolution  of  gas  resulting  from  the  addition 
of  an  acid  to  the  urine.  Concerning  its  diagnostic  signifi- 
cance consult  under  Reaction,  p.  183. 

Ammonia  appears  in  fresh  urine,  and  averages  in  amount 
daily  between  0.5  and  0.8  g.  It  is  increased  in  many 
diseases  of  the  liver  and  in  diabetes  to  6  g.      Such  an  in- 


204  THE    EXAMINATION   OF   THE   URINE  chap. 

crease  serves  as  a  guide  to  determine  the  severity  of  a  dia- 
betes. The  quantitative  estimation  is  made  by  the  addition 
of  chloride  of  lime  to  20  c.c.  of  urine,  to  which  has  also 
been  added  20  c.c.  of  sulphuric  acid  of  a  definitely  known 
composition.  The  mixture  should  be  prepared  in  a  shallow 
glass  vessel  under  a  bell  jar.  After  48  hours  the  change 
which  the  sulphuric  acid  has  undergone  is  measured  and 
from  the  amount  which  has  been  lost  the  formation  of  ]^Ho 
is  determined.  Ammonia  is  present  in  large  quantities  in 
old  decomposed  (alkaline)  urine ;  its  presence  may  be  dem- 
onstrated by  holding  a  piece  of  moistened  red  litmus  paper 
over  a  specimen  of  the  urine,  or  by  holding  a  glass  rod 
which  has  been  dipped  in  hydrochloric  acid  over  it  (cf. 
p.  183). 

Sodium  appears  in  daily  quantities  of  3  to  6  g.  Na^O ; 
potassium,  2  to  3  g.  K2O.  The  quantitative  estimation  of 
these  bodies  is  performed  according  to  the  rules  of  chemical 
analysis.  Their  presence  may  be  of  diagnostic  value  in 
some  cases  from  the  fact  that  in  all  cases  of  extensive 
albuminoid  disintegration,  such  as  occurs  in  fever  and  in 
inanition,  the  amount  of  j)otassium  salts  is  much  increased 
and  of  the  sodium  salts  much  diminished. 

2.    Organic  Elements 

+ 
Urea  (designated  often  by  clinicians  with  the  symbol  U) 

is  the  chief  end  product  of  the  metabolism  of  the  albu- 
minoids. 

Chemical  characters.  Urea  crystallizes  in  prisms  and  needles,  is 
soluble  in  alcohol  and  in  water,  insoluble  in  ether,  and  forms 
biuret  when  subjected  to  dry  heat.  This  latter  compound  will 
produce  a  red  color  when  added  to  a  potassium  hydrate  solution 
containing  some  drops  of  a  solution  of  cupric  sulphate  (biuret  re- 
action, see  p.  87).  By  the  action  of  the  bacteria  in  the  urine 
urea  becomes  transformed  into  ammonium  carbonate,  CO(ONH^)2. 

It  con)bines  with  the  formation  of  crystals,  with  nitric  acid,  and 
with  oxalic  acid. 


rut  THE   EXAMINATION   OF   THE    URINE  205 

The  normal  quantity  of  urea  depends  for  the  most  part 
on  the  amount  of  albumin  ingested  (see  Chap.  X.j  ;  it  varies 
between  20  and  40  g.,  Vjut  is  less  when  little  albuminous 
food  has  been  taken  and  is  physiologically  increased  after 
meals  rich  in  such  foods. 

Pathological  iyicrease  of  the  amount  of  urea  occurs  in  fever, 
in  many  cases  of  carcinoma,  in  antemia,  in  leucaemia,  in  intox- 
ications (phosphorus,  arsenic,  chloroform,  etc.,  jjoisoning), 
and  in  dyspnoea. 

Pathological  diminution  of  the  amount  of  the  urea  ex- 
creted occurs  in  inanition,  often  in  the  diffuse  diseases  of 
the  kidneys  (Bright's),  and  in  acute  yellow  atrophy  of  the 
liver. 

Qualitative  test  for  urea.  —  This  test  is  of  diagnostic  importance 
in  determining  the  presence  of  a  ursernic  condition,  in  which  con- 
dition the  vomited  matter,  the  sputum,  the  effusions,  and  the  blood 
may  all  contain  urea.  The  fluid  to  be  examined  for  this  should  be 
evaporated  to  the  consistency  of  syrup ;  the  urea  is  then  extracted 
by  alcohol,  the  solution  is  filtered,  the  alcohol  is  driven  off  by  dis- 
tillation, the  thick  liquid  remaining  is  diluted  with  water,  some 
concentrated  nitric  acid  is  added,  and  a  portion  examined  under 
the  microscope.  In  a  little  time  the  characteristic  hexagonal  crys- 
tals of  urea  nitrate  will  be  observed. 

Quantitative  estimation  of  urea.  —  This  is  of  great  diagnostic 
value  in  cases  of  diseases  of  metabolism  and  in  dietetics  (see 
Chap.  X.).  The  urea  is  not  determined  as  much  as  is  the  total 
quantity  of  nitrogen  which  appears  in  the  urine. 

Approximate  Estimation  by  Titration.      Liebig's  Method  modi- 
fied by  Pflüger 

From  a  graduated  burette  containing  a  solution  of  mercuric 
nitrate  of  definite  proportions,^  the  fluid  is  allowed  to  drop  gradu- 
ally into  a  test-tube  which  should  contain  10  c.c.  of  the  urine.  An 
insoluble  combination  of  urea  nitrate  and  mercuric  oxide  is  formed. 

1  In  irX)Oc.c.  of  the  solution  there  should  he  71.48  g.  of  mercury.  The 
X)reparation  of  the  solution  requires  a  great  deal  of  care;  it  may  be  pro- 
cured at  many  chemical  factories. 


206  THE   EXAMINATION  OF   THE   URINE  chap. 

Next  to  the  burette  a  watch  glass  with  a  black  bottom  should  be 
placed,  in  which  a  thick  mixture  of  powdered  XagCOg  and  water 
has  been  prepared.  As  long  as  the  mercuric  nitrate  is  united  with 
the  urea  in  the  urine,  it  can  not  react  to  NaaCOo ;  but  as  soon  as  all 
of  the  urea  is  used  up  in  the  former  combination,  the  Hg(N03)2 
which  will  now  exist  in  a  nascent  condition  will  combine  with  the 
Na^COg  to  form  2  NaXO.,  +  carbonic  acid  (which  will  arise  in  bub- 
bles) +  yellow  HgO.  The  urine  and  the  mercuric  nitrate  solution, 
as  it  drops  into  it,  should  be  stirred  thoroughly  with  a  glass  rod  ; 
the  thick  sodium  carbonate  mixture  should  then  be  stirred  with 
the  same  rod ;  as  soon  as  a.permanent  yellow  color  appears  at  the 
spot  of  the  thick  mixture  which  was  touched  by  the  rod,  the  titra- 
tion is  completed. 

The  number  of  cubic  centimetres  of  the  mercuric  nitrate  solu- 
tion used  in  the  test  is  multiplied  by  O.Oi  to  obtain  the  percentage 
of  nitrogen  in  the  urine.  For  example,  21  c.c.  of  the  Hg  solution 
were  used  in  10  c.c.  of  urine  ;  .-.  21  x  0.04  =  0.81  %  of  X.  If  the 
urine  passed  in  21  hours  happened  to  be  1500  c.c,  then  the  daily 
excretion  of  N  would  be  12.6  g.,  which  equals  27  g.  of  urea, 
because  the  amount  of  nitrogen  is  to  the  urea  as  1  is  to  2.143  or 

+  +  . 

N :  U  : :  1  :  2.143,  from  which  U  was  determmed. 

This  method  is  for  clinical  purposes  entirely  reliable.  A  more 
exact  method  used  requires  too  many  details  which  must  be  care- 
fully carried  out,  such  as  precipitating  the  phosphates  and  sulphates 
in  the  urine  by  a  solution  of  baryta,  the  reduction  of  the  acidity 
which  arises  in  the  process  of  titration,  the  repeated  addition  of 
mercuric  nitrate  solution,  etc. 

The  method  now  used  in  all  clinical  laboratories,  one  which  is 
entirely  reliable,  for  determining  the  amount  of  nitrogen  is  that 
first  recommended  by  Kjeldnhl.  It  is  carried  out  in  this  way :  5  c.c. 
of  urine  and  20  c.c.  of  fuming  sulphuric  acid  are  placed  in  a  flask, 
which  is  then  held  over  a  flame  until  it  boils,  when  the  fluid  loses 
its  color.  The  solution  is  then  diluted  with  100  c.c.  of  sodium 
hydrate  whose  specific  gravity  is  1.3  and  distilled  in  a  distilling 
apparatus ;  öO  or  100  c.c.  of  a  yL  normal  acid  (sulphuric)  is  titrated 
after  the  distillation  with  a  J^  potassium  hydrate  solution.  (All 
of  the  N  of  the  urine  is  converted  into  XH^,  which  becomes 
united  with  the  excess  of  sulphuric  acid  into  (XH^)2S04;  the 
XaHO  sets  the  NII3  free,  and  the  latter  immediately  combines  in 
part  with  the  prepared  y^^  solution  of  normal  sulphuric  acid ;  the 
part  which  remains  is  determined  by  titration  and  from  it  is  reck- 


vm  THE   EXAMINATION   OF   THE   URINE  207 

oned  the  entire  amount  of  NHg,  from  which  in  turn  the  amount 
of  N  contained  in  the  original  5  c.c.  of  urine  is  determined). 

Example:  5  c.c.  of  nrine  were  oxidized;  50  c.c.  of  y\f  II.,SO^  were 
prepared;  after  the  distillation  12  c.c.  of  j^y  NaOH  in  the  titration 
of  the  acid  remaining-  free,  therefore  only  12  c.c.  of  the  J^  IJ2^^'^4 
remained  free ;  therefore  38  c.c.  of  the  -^^  HgSO^  must  have  been 
used  in  combining  with  the  NH^  which  distilled  over.  For  the 
combination  of  38  c.c.  of  the  j\,  normal  acid,  that  is,  38  x  0.049  g. 
H2SO4,  38x0.0017^113  are  necessary;  and  the  amount  of  nitrogen 
corresponding  would  be  38  x  0.0014  g.,  which  would  be  equal  to 
0.0532  g,  of  N.  Now  since  this  amount  was  contained  in  5  c.c.  of 
urine,  the  entire  percentage  in  the  amount  would  be  1.064. 

Uric  acid  (C-H^N^Oo)  is  excreted  in  the  urine,  the  daily  amount 
being  from  0.4  to  1.4  g.  The  quantity  varies  in  different  persons 
and  at  different  times.  The  uric  acid  (togetlier  with  the  xanthin 
bases)  arises  from  the  disintegration  of  the  nuclein  which  is  con- 
tained in  all  cell  bodies.  The  uric  acid  appears  in  the  urine  in 
solution  as  neutral  sodium  urate ;  in  very  acid  and  in  very  concen- 
trated urine  (such  as  occurs  in  fever  and  in  congestion  of  the 
organs,  in  cases  where  a  small  amount  of  fluids  is  taken,  and  in 
profuse  perspiration)  acid  sodium  urate  or  pure  uric  acid  is  some- 
times precipitated  when  the  urine  becomes  cold  (see  nrinary 
sediments). 

Uric  acid  excretion  is  increased  in  all  conditions  of  increased 
destruction  of  leucocytes,  in  leucaemia  (the  proportion  in  the 
urine  is  1  to  16),  after  the  ingestion  of  food  rich  in  nuclein.  In 
gout  the  excretion  of  uric  acid  varies  remarkably. 

The  qualitative  determination  of  uric  acid  is  sometimes  of 
value  in  the  examination  of  sediments  and  concretions  (see  below), 
and  is  performed  by  means  of  the  murexide  test,  which  is  the 
following  :  — 

To  the  specimen  to  be  examined  3  or  4  drops  of  concentrated 
nitric  acid  are  added  in  a  porcelain  dish  and  the  contents  of  the 
dish  evaporated  to  dryness ;  if  uric  acid  be  present  in  the  specimen, 
an  orange-yellow  color  will  be  produced,  which  will  be  changed  by 
the  addition  of  ammonia  to  be  a  purple-red. 

The  qualitative  examination  for  its  presence  in  the  hlood  is  car- 
ried out  as  was  suggested  by  Garrod  with  a  thread,  constituting 
Garrod's  thread  test.  The  method  is  as  follows  :  10  c.c.  of  blood  are 
obtained  by  wet  cupping  ;  the  blood  is  permitted  to  coagulate  and 
to  settle  in  the  cup,  the  serum  is  transferred  into  a  watch  glass. 
rendered  acid  with  some  30  per  cent,  acetic  acid,  and  in  the  mixt- 


208  THE   EXAMINATION  OF   THE  URIKE  chap. 

ure  a  tliin  linen  thread  is  placed.  The  glass  should  remain  cov- 
ered for  24  hours,  when  it  is  examined  under  a  low  power  of  the 
microscope ;  should  uric  acid  liave  been  present,  many  crystals  of 
it  will  be  found  adhering  to  the  thread.  Its  presence  occurs  in 
attacks  of  gout  and  in  nephritis. 

To  estimate  uric  acid  quantitatively,  the  urine  should  be  mixed 
with  magnesia  and  silver  nitrate;  the  resulting  urates  of  magnesia 
and  silver  are  then  combined  with  sulphuretted  hydrogen  and  the 
amount  of  uric  acid  determined  by  weighing.  For  an  exact 
description  consult  the  various  text-books  on  chemical  analysis. 

Oxalic  acid  (COOH  .  COOH)  is  excreted  to  the  amount  of  0.02  g. 
in  the  2-1  hours,  either  in  solution  or  as  a  sediment  of  calcium 
oxalate  (see  below). 

Xanthin  bases  (xanthin  CgH^N'^O.^,  hypoxanthin  C^H^N^O)  ap- 
pear in  small  quantities  in  the  urine  and  result,  like  uric  acid, 
from  the  disintegration  of  nuclein  substances.  ^The  sum  total  of 
uric  acid  and  xanthin  bases  are  designated  as  alloxan  bodies.  Con- 
sult text-books  for  the  quantitative  determination.  The  alloxan 
bodies  are  increased  in  all  conditions  which  involve  augmented 
disintegration  of  leucocytes. 

Kreatinin  (C^H-NoO),  daily  quantity  from  0.6  to  1.3  g.,  is  with- 
out diagnostic  importance,  as  is 

Hippuric  acid  (CgH^NOg),  whose  daily  amount  of  excretion  is 
between  0.2.5  and  0.5  g.,  and  which  is  formed  from  benzoic  acid 
(CßH.COOH)  and  giycocol  (CHaNH^COOH). 


Indican  (C8H6]SrKS04),  potassium  indoxyl  sulphate,  present 
in  small  quantities  in  the  urine,  is  increased  in  cases  of  ex- 
tensive decomposition  in  the  intestinal  tract,  therefore  in 
all  diseases  of  the  abdominal  cavity  which  tend  to  diminish 
peristalsis  and  hinder  absorption,  especially  in  peritonitis 
and  intestinal  obstruction;  at  the  same  time  the  amount  of 
indican  is  greater  the  higher  the  obstruction  is  situated. 
Obstruction  of  the  large  intestine  gives  rise  to  but  little 
indican.  Indican  is  also  increased  in  cases  of  putrid  sup- 
puration. 

Chemical  attributes  of  indican.  From  the  decomposition  of  albu- 
minoids in  the  intestine  or  in  foci  of  suppuration  indol  (CgH-N) 
is  produced;  indol  is  oxidized  in  the  organism  into  indoxyl ;  like 


viii  THE   EXAMINATION   OF   THE   URINE  209 

all  aromatic  compounds,  indoxyl  combines  with  sulphuric  acid. 
The  test  for  indican  is  based  on  the  development  of  indigo  l)lue. 

Test  for  indican  in  the  urine.  The  specimen  of  urine  is  mixed 
with  an  equal  volume  of  hydrochloric  acid ;  fresh  chloride  of  lime 
solution  is  then  adTled  drop  by  drop  while  tlie  mixture  is  being 
stirred.  The  chloride  of  lime  solution  should  be  composed  of  5 
parts  of  chlorinated  lime  and  1000  parts  of  distilled  water.  If 
indican  be  abundantly  present,  the  urine  will  turn  to  a  blue  color, 
or  a  precipitate  of  indigo  in  the  shape  of  blue  flakes  will  take  place. 
By  the  addition  of  ether  or  chloroform  the  indigo  blue  will  be  re- 
moved. Very  dark  .urine  should,  before  the  test  is  applied,  be 
mixed  wdth  some  plumbic  acetate  and  then  filtered. 

Indigo  red  is  demonstrated  by  boiling  the  urine  and  then  adding 
some  nitric  acid  drop  by  drop,  while  carefully  continuing  the  boil- 
ing process  until  a  deep-red  color  appears.  Should  the  mixture 
then  be  shaken,  the  froth  will  assume  a  blue-violet  color,  which  is 
at  once  removed  by  the  addition  of  chloroform  or  ether.  This 
constitutes  Rosenbach's  reaction.  The  composition  of  indigo  red  is 
not  as  yet  known ;  this  reaction  occurs  quite  in  parallelism  with 
the  indigo  blue  reaction  in  the  urine  of  cases  of  severe  intestinal 
affections,  although  one  or  the  other  may  be  demonstrated  in  mild 
cases. 

Phenols :  CgHsOH  is  carbolic  acid  or  ^^henol ;  C6H4CH3OH 
is  cresol ;  they  occur  in  the  urine  combined  with  sulphuric 
acid  (sulphuric  ether).  In  the  normal  state  0.017  to  0.05  g. 
of  phenols  are  excreted ;  increase  in  this  amount  to  0.06  g. 
occurs  in  cases  of  decomposition  occurring  within  the  or- 
ganism, in  which  cases  the  excretion  of  phenols  offers  a 
diagnostic  measure  of  great  value  in  determining  the  inten- 
sity of  the  process. 

Test  for  phenol :  200  c.c.  of  urine  are  mixed  with  40  c.c.  of 
hydrochloric  acid  and  distilled  until  150  c.c.  have  gone  over 
into  the  receiver ;  an  aqueous  solution  of  bromine  is  added 
to  the  distilled  portion  until  it  assumes  a  yellow  color.  A 
precipitate  will  be  formed  if  phenol  be  present.  The  pre- 
cipitate is  tribromphenol.  By  weighing  this  the  amount  of 
phenol  in  the  entire  urine  may  be  determined. 


210  THE    EXAMINATION  OF   THE  URINE  chap. 

EXAMIXATIOX    OF    THE    UrIXARY    SeDIMEXTS 

If  the  urine  be  very  cloudy,  or  if  it  contain  a  sediment,  pour  it 
into  a  conical  glass  and  permit  the  deposit  to  collect  for  several 
hours ;  then  pour  off  the  superambient  fluid  a'^id  place  a  specimen 
of  the  sediment  upon  the  slide  for  microscopical  examination. 

For  the  speedy  collection  of  a  scauty  sediment  use  a  sedimenta- 
tor  (centrifuge  apparatus^. 

Before  using  the  microscope,  test  the  reaction  of  the  urine  and 
heat  a  sample  so  as  to  gain  some  knowledge  as  to  its  constituents. 
For  if  the  urine  be  acid  and  cloudy  and  the  cloudiness  disap- 
pears on  heating,  the  sediment  will  be  recognized  as  composed  of 
urates  chiefly.  Should  the  urine  be  acid  and  the  cloudiness  does 
not  disappear  on  heating,  but  on  the  addition  of  potassium  hy- 
drate, then  the  sediment  is  due  to  uric  acid.  If  the  urine  was 
alkaline  and  cloudy  and  the  cloudiness  disappeared  on  the  addi- 
tion of  hydrochloric  acid  with  or  without  the  evolution  of  gas, 
then  it  may  be  considered  that  the  sediment  was  composed  of  lime 
carbonate  or  phosphate. 

UXORGAXIZED    SeDIMEX^TS 

In  Acid  Urine 

Add  sodium  urates  (Fig.  35)  are  amorphous  granules  col- 
lected in  clusters,  usually  colored  yellow.  They  form  the 
brick-dust  deposit  (sedimentum  later itium),  are  soluble  on 
heating  as  well  as  on  the  addition  of  potassium  hydrate. 
On  adding  some  hydrochloric  acid  to  a  specimen  under  the 
microscope,  crystallization  of  uric  acid  may  be  observed. 
They  are  of  no  diagnostic  importance,  and  indicate  only  the 
acid  condition  and  concentration  of  the  urine. 

Uric  acid  (Fig.  35)  occurs  in  the  shape  of  ^vhetstones,  and 
in  cylinders  (also  in  the  shape  of  spears  and  rosettes)  chiefly 
of  a  yellow^  color ;  it  dissolves  on  the  addition  of  ]3otassium 
hydrate,  but  not  on  heating.  It  is  recognized  outside  of  the 
shape  of  its  crystals  by  the  murexide  reaction  (see  p.  207). 
An  abundant  deposit  of  uric  acid  does  not  in  itself  denote 
that  the  uric  acid  is  increased,  but  often  only  that  the  con- 


VIII 


THE   EXAMINATION   OF   THE    URINE 


211 


clitioiis  of  solubility  are  unfavorable,  either  because  there  is 
too  small  au  amount  of  water,  or  because  there  is  too  much 
acid  in  the  urine  ;  still,  when  abundantly  present,  it  should 
demand  a  quantitative  analysis.  An  abundant  uric  acid 
deposit  in  the  urine  indicates  the  presence  of  the  so-called 
condition  of  uric  acid  diathesis  (jiephritis  urica,  arthritis 
urica). 


Uric  acid  crystals. 


Sodium  urate  crystals. 
/ 


Calcium  oxalate  crystal. 
Fig.  35.  —  Urinary  Deposits  in  Acid  Urine. 


Oxalate  of  lime  (Fig.  35)  (the  reaction  of  the  urine  is 
nearly  neutral)  forms  in  octahedral  crystals.  If  present 
only  as  solitary  crystals,  it  has  no  significance ;  even  an 
abundance  of  them  in  the  urinary  deposit  does  not  always 
indicate  an  increase  in  the  excretion  of  oxalic  acid  ;  to  deter- 
mine this  a  quantitative  analysis  is  necessary. 

Cystin  occurs  rarely  as  a  deposit.  When  it  does  it  is  pathogno- 
monic of  a  special  form  of  metabolic  disturbance  (see  Chap.  X.). 
It  consists  of  hexagonal  crystals  which  are  readily  soluble  in  am- 
monia. 


212 


THE   EXAMINATION   OF   THE   URINE 


CHAP. 


Leucin  (amido-capronic  acid)  (Fig.  36)  and  tyrosin  (amido- 
paracumaric  acid)  are  likewise  rarely  found  as  urinary  deposits ; 
they  occur  in  the  urine  in  cases  of  acute  yellow  atrophy  of  the  liver 
and  in  poisoning  by  phosphorus.  Leucin  crystallizes  in  yellow- 
white  crystals  which  are  often  in  the  shape  of  striped  radiatory 
globules  ;  tyrosin  crystallizes  as  beautiful  needle-like  bundles. 


Leucin. 


pow 


Tyrosin.  Leucin. 

Fig.  36.  —  Sediment  of  Ukine  in  Acute  Yellow  Atrophy  of  the  Liveb. 


In  Alkaline  Urine  (Fig.  37) 

The  ammonio-magnesia  phosphates  or  tn'j^le  phosphates 
(NH4MgP04  4-  6  H.^0)  crystallize  in  coffin-like  crystals 
which  are  very  readily  soluble  in  acetic  acid. 

Phospjhate  of  lime  occurs  either  as  Ca3(P04)2  in  the  form 
of  irregular  granules,  or  as  CaTlP04  in  cuneiform  crystals, 
which  are  usually  collected  together  in  masses  and  often  in 
rosettes. 

Carbonate  of  lime  (CaCOs)  occurs  as  round  regular  granules 
or  in  the  shape  of  dumb-bells,  and  dissolves  on  the  addition 
of  an  acid  with  an  evolution  of  gas. 


VIII 


THE   EXAMINATION   OF   THE   URINE 


213 


Ammonium  urate  occurs  in  the  shape  of  pine  cones,  or  in 
irregular  fusiform  crystals. 

The  alkaline  deposits,  outside  of  indicating  the  reaction 
of  the  urine  (see  above),  have  no  farther  diagnostic  signifi- 
cance. 


Triple  ^) 

phosphate.    Sy^/ 


Calcium 
carbonate. 


\\_    Calcium 

phosphate. 


Ammonium  urate. 
Fig.  3T.  —  Sedlment  of  Ammoniacal  Ueine. 


Organized  Sediments  (Figs.  38  and  39) 

These  are  of  the  utmost  importance  in  the  diagnosis  of 
diseases  of  the  kidneys  (see  Chap.  IX.). 

White  blood  corpuscles  (leucocytes)  appear  sparsely  in  the 
urine  of  healthy  persons ;  should  they  be  abundant,  hov^- 
ever,  it  indicates  an  inflammation  or  a  suppuration  in  some 
spot  along  the  genito-urinary  tract,  a  nephritis,  pyelitis, 
cystitis,  gonorrhoea,  or  a  leucorrhoea  in  women. 

Red  blood  corpuscles  occur  mostly  as  pale  corpuscles,  owing 
to  imbibition  of  water ;  they  indicate  the  presence  of  a 
hsemorrhage  somewhere  in  the  genito-urinary  apparatus  (see 
haematuria,  p.  189). 


214  THE    EXAMINATION   OF   THE    URINE  chap. 

Renal  epithelium  (Fig.  38)  occur  as  round  or  cubical  cells 
containing  nuclei,  and  indicate  chiefly  an  affection  of  the 
kidney.  They  often  coalesce  into  epithelial  casts.  Fatty 
epithelial  cells  (masses  of  fat  granules)  are  of  the  utmost 
diagnostic  importance  (Fig.  39) ;  they  indicate  chronic  par- 
enchymatous nephritis  in  the  2d  stage  of  a  fatty  degen- 
eration. 

Epithelium  from  the  renal  'pelvis,  of  the  ureters,  and  of  the 
bladder  can  not  be  distinguished  from  each  other ;  they  occur 
either  as  flat  polygonal,  or  more  or  less  round  cells,  provided 
with  processes  and  in  part  containing  nuclei.  An  abun- 
dance of  these  cells  in  the  urine  justifies  the  diagnosis  of  a 
pyelitis,  of  a  cystitis,  or  of  an  inflammation  of  the  ureter 
(see  differential  diagnosis,  Chap.  IX.). 

Epithelium  from  the  vagina  consists  of  large  flat  epithelium 
like  the  buccal  epithelium  ;  epithelium  from  the  male  urethra 
is  of  the  cylindrical  variety,  and  appears  sometimes  in 
gonorrhoeal  pus. 

Casts  in  the  urine  are  probably  exudations  from  the  renal 
tubules.     They  appear  as :  — 

1.  Jlyaline  casts,  which  are  small,  transparent,  homogene- 

ous formations,  with  not  very  definite  contours. 
Their  presence  is  not  a  proof  of  nephritis.  They 
occur  also  in  congestion,  in  fever,  and  in  jaundice, 
and  even  in  very  small  quantities  in  the  healthy 
person. 

2.  Epithelial  casts,  consisting  of  agglutinated   epithelial 

cells,  indicate  the  presence  of  a  nephritis ;  they  are 
often  deformed,  more  or  less  granular  {granular 
casts),  and  often  are  covered  by  fatty  epithelial  cells. 

3.  Blood  casts  occur  only  in  haemorrhage  of  the  kidneys. 

4.  Waxy  casts  have  sharp  outlines,  a  yellow  glistening 

appearance,  and  occur  only  in  chronic  nephritis. 

5.  Brovni  casts  occur  rarely  in  severe  infectious  diseases, 

and  in  fractures  of  bones. 


vm 


THE   EXAMINATION   OF   THE    URINE 


215 


Epithelial         Renal  epi- 
cast.  thelium. 


Hyaline  cast  con- 
taining red 
blood-cells. 


Hyaline  casts. 


Renal  epithelium. 
Fig.  33.  —  Sediment  ix  Acute  Nephritis. 


Granular  casts.  Fatty  renal  epithelium. 


Granular  casts  con-       j  j 
taining    fat     and    n 
leucocytes. 


axy  casts. 


Red  blood-cells. 
Fig.  39.  —  Sediment  in  Chkonic  Nephritis. 


216  THE   EXAMINATION   OF  THE    URINE  chap. 

Cylindrical  formations  which  look  like  casts  are  often  seen ; 
they  are  produced  by  accumulations  of  bacteria  or  of  amorphous 
urates. 

Micro-organisms  may  occur  in  the  urine  in  many  infec- 
tious diseases  (diphtheria,  relapsing  fever,  8.nd  in  typhoid 
fever).  The  presence  of  gonococci  and  of  tubercle  bacilli 
have  of  course  a  diagnostic  significance.  In  cystitis  and 
in  pyelonephritis  an  abundance  of  microbes  appear  in 
the  freshly  voided  urine.  (For  their  demonstration,  see 
Chap.  XII.) 

Parasites  have  been  observed  in  rare  cases  in  the  urine  in  the 
shape  of  particles  of  echinococcus,  embryos  of  Filar ia  sanguinis, 
which,  like  the  Distoma  hcematobium,  have  given  rise  to  haema- 
turia. 


Tests  for  Certain  Heterogeneous  Substances 

OCCURRING    IN    THE    UrINE 

The  determination  of  the  presence  of  foreign  substances  in  the 
urine  is  of  importance  in  diagnosing  the  various  intoxications. 
Irrespective  of  this,  it  is  often  of  interest  from  a  therapeutic 
standpoint  w^hether  a  substance  has  been  absorbed  by  the  organ- 
ism. Finally,  by  demonstrating  the  presence  of  a  medicine  in  the 
urine,  we  may  be  able  to  form  opinions  concerning  the  patient's 
statements. 

Iodine  appears  in  the  urine  after  the  use  of  potassium  iodide 
and  iodoform.  Add  to  the  urine  a  few  drops  of  fuming  nitric 
acid,  or  of  an  aqueous  solution  of  chlorine,  and  a  few  cubic 
centimetres  of  chloroform  ;  then  shake  the  test-tube  containing 
the  mixture ;  should  iodine  be  present,  the  chloroform  will  assume 
a  red-violet  color. 

Bromine  appears  in  the  urine  after  the  use  of  the  bromides. 
Test  in  the  same  manner  as  for  iodine.  When  large  quantities 
are  present,  the  chloroform  will  become  yellow.  The  test  will  not 
detect  a  small  quantity.  In  the  latter  case,  we  render  the  urine 
alkaline  with  sodium  carbonate,  and  add  to  it  2  g.  of  potas- 
sium nitrate.  Pour  the  mixture  then  into  a  platinum  dish,  and 
evaporate  and  heat  the  dry  residue  until  it  melts.     The  residue, 


VIII  THE   EXAMINATION   OF   THE    URINE  217 

when  cooled,  is  dissolved  in  water  rendered  strongly  acid  with 
hydrochloric  acid,  and  is  then  shaken  witli  chloroform.  With  this 
test,  if  the  urine  contains  only  a  very  small  quantity  of  bromine, 
the  chloroform  will  become  yellow. 

Iron.  —  Urine  containing  much  iron  will  become  greenish-black 
on  the  addition  of  ammonium  sulphide.  To  test  the  presence  of 
only  a  small  quantity  of  iron,  .50  c.c.  of  urine  are  evaporated  in  a 
platinum  dish,  the  dry  residue  is  converted  into  an  ash,  and  then 
the  ash  is  subjected  to  the  action  of  a  weak  solution  of  hydrochloric 
acid.  Should  iron  be  present,  a  blue  precipitate  will  result  after 
the  addition  of  some  potassium  ferrocyanide. 

Arsenic.  —  In  order  to  successfully  carry  out  the  test  for  arsenic, 
the  organic  substances  in  the  urine  must  be  removed.  U'his  may 
be  done  as  follows :  one  or  two  litres  of  urine  are  evaporated  in  a 
porcelain  dish  to  i  of  its  volume ;  then  an  equal  volume  of  concen- 
trated hydrochloric  acid  is  added  to  the  residue  and  the  mixture 
covered  and  placed  on  a  water  bath.  At  regular  intervals  during 
the  heating  on  the  bath,  2  or  3  g.  potassium  chlorate  are  added, 
until  the  mixture  becomes  entirely  light  yellow.  It  is  then  rapidly 
heated  and  boiled  until  all  smell  of  chlorine  disappears,  when  it  is 
strongly  diluted  with  water.  For  many  hours  after  this,  sulphu- 
retted hydrogen  is  passed  through  the  solution,  producing  a  pre- 
cipitate of  arsenic  sulphide,  which,  is  removed  by  filtration,  dried, 
dissolved  in  a  small  dish  by  a  mixture  of  a  few  drops  of  nitric  and 
sulphuric  acids,  heated  until  the  acid  smell  has  disappeared,  then 
strongly  diluted  with  water,  and  the  remaining  solution  is  then 
subjected  to  the  Marsh  mirror  test  for  arsenic. 

The  Marsh  test  is  performed  in  the  simplest  way,  as  follows  :  a 
test-tube  is  provided  with  a  cork  in  which  a  hole  has  been  bored ; 
into  the  hole  one  end  of  a  glass  tube  —  which  has  been  bent  to  a 
desirable  angle,  and  whose  other  extremity  has  been  drawn  out  to 
a  capillary  point  —  is  introduced.  The  test-tube  is  now  filled  with 
zinc  and  dilute  sulphuric  acid,  and  with  some  of  the  previously 
prepared  solution  of  urine.  Gas  will  be  immediately  evolved,  when 
the  cork  and  attached  glass  tube  should  be  introduced  into  the 
mouth  of  the  test-tube.  When  the  gas  is  streaming  off  strongly, 
the  gas  at  the  capillary  end  of  the  tube  should  be  ignited  by  a 
match.  If  arsenic  be  present  in  the  solution,  the  gas  will  burn 
with  a  blue  flame,  and  if  a  clean,  dry,  porcelain  plate  be  held  over 
the  flame,  a  mirror  of  deposited  arsenic  will  form  on  the  plate. 
This  mirror  has  a  metallic,  glistening  appearance,  and  will  be 
dissolved  by  a  solution  of  sodium  h}^ochlorite. 


218  THE   EXAMINATION   OF   THE   URINE  chap. 

Lead.  —  The  organic  substances  should  be  disintegrated  by  hy- 
drochloric acid  and  potassium  chlorate,  as  was  done  in  the  test  for 
arsenic  (see  above),  and,  through  the  diluted  mixture,  which  has 
been  thereby  rendered  weakly  acid,  sulphuretted  hydrogen  is  per- 
mitted to  pass ;  this  will  form  a  precipitate  of  the  brownish-black 
plumbic  sulphide  when  lead  is  present. 

Mercury.  —  About  1  litre  of  urine  is  heated  to  60°  to  80°  C, 
made  acid  by  the  addition  of  hydrochloric  acid,  and  then  thor- 
oughly oxidized  by  the  addition  of  fine  copper  filings  (lametta). 
After  an  hour,  the  urine  is  decanted ;  the  copper  filings  are  washed 
with  hot  water,  then  with  alcohol,  and  finally  with  ether,  and 
thoroughly  dried  between  laj^ers  of  filter  paper.  The  filings  are 
then  placed  in  a  small  glass  tube,  which  is  thereafter  drawn  out 
at  both  ends  into  capillary  points.  The  tube  is  then  heated  in  the 
flame,  the  mercury  becomes  sublimed,  and  in  the  capillary  ends 
metallic,  silver-like  rings  will  have  formed.  If  a  small  piece  of 
iodine  has  been  put  in  the  tube  before  the  ends  of  the  tube  have 
been  drawn  out,  the  red  mercuric  iodide  would  be  formed  in- 
stead. 

Carbolic  acid.  —  If  much  carbolic  has  been  taken,  the  urine  will 
have  a  greenish-brown  appearance,  and  by  exposure  to  the  air  it 
will  become  darker.  The  same  color  results  from  the  ingestion  of 
hydroquinon  and  from  uva  ursi.  The  test  for  carbolic  acid  is  made 
by  adding  bromine  water  to  the  distilled  mixture  (see  p.  209),  or 
by  the  test  for  the  presence  of  the  sulphuric  ethers  (see  p.  203). 

Quinine.  —  Shake  well  a  large  quantity  of  urine,  to  which  some 
ammonia  has  been  added,  with  ether.  This  will  take  up  the 
quinine.  The  residue  left  after  evaporating  the  ether  is  mixed 
with  acidulated  water.  The  mixture  is  then  subjected  to  the 
action  of  chlorine  water,  and  after  that  to  ammonia.  A  green 
color  will  develop  if  quinine  be  present. 

Salicylic  acid  (CJI^OH  .  COOH).  — The  urine  will  give  a  blue- 
violet  color  if  ferric  chloride  be  added.  Should  the  reaction  to 
this  be  negative,  acidulate  in  a  graduate  30  c.c.  of  urine  with  sul- 
phuric acid,  and  add  to  it  30  c.c.  of  ether;  then  shake  the  mixture 
thoroughly,  pour  oft'  the  ether,  and  to  the  latter  add  some  of  a 
ferric  chloride  solution  drop  by  drop.  A  blue  color  will  ensue 
even  where  the  quantity  of  salicylic  acid  present  is  very  small. 

Antipyrin.  —  A  red  color  is  produced  by  the  addition  of  ferric 
chloride  to  the  urine. 

Antifebrin.  —  A  red  color  is  produced  when  the  urine  is  boiled 
with  hydrochloric  acid  and  afterwards  mixed  with  some  of  a  3  per 


viii  THE   EXAMINATION   OF  THE   URINE  2l9 

cent,  carbolic  solution  and  with  ferric  chloride ;  on  the  addition  of 
ammonia,  it  changes  to  a  blue  color. 

Phenacetin. —  A  brownish-red  color  will  ensue  on  the  addition 
of  ferric  chloride. 

Tannin. —  ^Vith  ferric  chloride  the  urine  becomes  dark  blue, 
almost  black. 

Napthalin.  —  After  the  ingestion  of  large  doses,  the  urine  will  be 
turned  to  a  green  color  by  the  addition  of  concentrated  sulphuric 
acid. 

Turpentine.  —  The  urine  has  an  odor  of  violets. 

Rhubarb  and  senna  (chrysophanic  acid).  —  The  urine  becomes 
purple-red  on  the  addition  of  sodium  hydrate.  Sodium  carbonate 
will  also  produce  the  same  reaction. 

Santonin.  —  The  urine,  when  santonin  has  been  taken,  has  a 
straw  color,  which  is  turned  to  red  by  the  addition  of  sodium 
hydrate.  Sodium  carbonate,  however,  will  not  produce  the  red 
color. 


CHAPTER    IX 

DIAGNOSIS   OF  THE  DISEASES   OF  THE   KIDNEYS 

The   Diffuse   Diseases    of    the    Kidneys    (Bright's 

Disease) 

The  diffuse  diseases  of  the  kidneys  are  recognized  by  the 
simultaneous  presence  of  oedema  and  albuminuria ;  they 
are  classified  under  the  head  of  Brighfs  disease.  The  spe- 
cific diagnosis  of  the  form  of  Bright's  disease  present  is 
decided  chiefly  by  the  examination  of  the  urine  (see  Chap. 
VIII.),  and,  in  addition  to  this,  by  the  history,  the  course  of 
the  disease,  and  b}^  the  examination  of  the  other  organs 
(heart,  vessels,  liver,  spleen,  and  the  eyes). 

In  reference  to  the  history,  the  following  data  are  especially  im- 
portant :  alcoholism  often  leads  to  the  production  of  a  chronic 
nephritis ;  chronic  intoxications  and  gout  lead  frequently  to  the 
primary  atrophy  of  the  kidney ;  severe  exposure,  frequent  drench- 
ing of  the  skin,  the  action  of  the  toxic  agents,  especially  the  acute 
infectious  diseases  (scarlatina,  etc.),  are  potent  in  producing  acute 
nephritis.  Tertiary  syphilis,  suppuration,  phthisis,  and  malaria  may 
lead  to  amyloid  degeneration  of  the  kidney.  Inquiry  should  always 
be  made  as  to  the  duration  and  course  of  the  disease,  and  the 
investigation  should  elicit  whether  there  have  been  previously  any 
nephritic  syniptoms,  such  as  oedema,  urinary  changes,  headaches, 
vomiting,  asthma,  and  visual  disturbances. 

Concerning  oedema,  see  p.  10.  For  the  tests  for  albu- 
min, see  p.  186. 

In  many  periods  and  in  many  forms  of  Bright's  disease  either 
oedema  or  albuminuria  may  be  absent,  and  not  alone  this,  but  in 
some  rare  cases  both  may  for  a  time  be  wanting.     Under  these 

220 


CHAP.  IX 


THE   DISEASES   OF   THE    KIDNEYS 


221 


circumstances  the  consideration  of  the  course  of  the  disease,  the 
examination  of  the  heart  (cardiac  hypertrophy  in  atropic  kidney) 
and  of  the  pulse,  and  often  the  large  quantities  of  urine  will  aid 
the  diagnosis.  In  spite  of  these  exceptions  it  is  wise  to  establish 
the  rule  that  oedema  and  albuminuria  are  the  cardinal  symptoms 
of  diffuse  diseases  of  the  kidneys. 

In  order  to  make  a  diagnosis  of  the  form  of  Bright's 
disease  present  in  each  case,  it  is  best  to  fix  in  the  mind  a 
systematized  scheme  of  the  various  forms  of  the  disease 
which  occur. 

BRIGHT'S   DISEASE 

QEdema  with  Albuminukia 


Inflammatort  Form 

Non-inflammatory  Form 

Eirst  stage    .  . 

Acute      hsemorrhagic 

QCdema    from   venous   stasis 

nephritis. 

(chronic  congested  kidney). 

Second  stage  . 

Chronic        nephritis ; 
fatty  degeneration. 

Amyloid  degeneration. 

Third  stage  .  . 

Secondary     atrophy ; 

Primary   atrophy   (red   atro- 

white atrophic  kid- 

phic  kidney  ;    arterio-scle- 

ney. 

rotic,   lead,  and  gout  kid- 
neys). 

In  a  class  by  themselves  are  the  cedema  and  albuminuria 
of  pregnancy  —  the  kidneys  of  pregnancy. 

In  the  first  column  of  this  table  or  scheme  the  forms  of 
nephritis  are  mentioned,  as  well  as  how  they  sometimes 
develop  in  order  from  one  form  to  the  other ;  still  the 
chronic  form  may  occur  primarily  without  there  having 
been  an  acute  inflammation  before  its  development. 

Clinical  diagnosis  must  renounce  deciding  between  the 
presence  of  an  interstitial  and  a  parenchymatous  inflamma- 
tion, because  the  symptoms  do  not  in  most  respects  har- 
monize with  the  pathological  anatomical  processes.  Still 
the  proof  of  the  existence  of  fat  in  the  urinary  deposit  is 


222  THE   DISEASES   OF  THE   KIDNEYS  chap. 

a  positive  indication  of  a  parenchymatous  process,  while,  on 
the  other  hand,  the  absence  of  an  essential  sediment  in  the 
urine  would  point  to  an  interstitial  inflammation. 

In  the  second  column  those  forms  are  mentioned  which 
exist  individually  and  which  are  not  related  to  each  other, 
but  which  in  their  clinical  features  very  much  resemble  the 
forms  adjoining  them  in  the  first  column. 

The  chronic  congested  kidney  strictly  should  not  belong 
to  this  group,  but  clinically  it  gives  a  symptom  picture  so 
closely  resembling  the  essential  forms  of  Bright's  disease 
that  it  appeared  to  the  author  justifiable  to  place  it  in  the 
table. 

Chief  Symptoms  of  the  Various  Forms  of  Bright's 

Disease 

Acute  haemorrhagic  nephritis  presents  the  following  clinical 
features:  generally  severe  anasarca,  and  especially  oedema 
of  the  face.  The  urine  contains  much  albumin  and  a  good 
deal  of  blood.  Its  quantity  is  much  diminished,  and  its 
specific  gravity  is  high.  The  sediment  will  be  found  to 
consist  of  red  blood  corpuscles,  hyaline  and  granular  casts 
as  well  as  blood  and  epithelial  cells. 

The  diagnosis  should  include  an  inquiry  into  the  etiologi- 
cal factor  :  is  it  a  nephritis  due  to  an  infection,  to  a  poison, 
or  to  exposure  ?  or  is  it  an  exacerbation  of  the  chronic  form  ? 
The  prognosis  is  essentially  influenced  by  the  quantity  of 
urine  and  the  presence  of  urgemic  symptoms  (headache, 
vomiting,  coma,  and  convulsions). 

Chronic  nephritis,  fatty  degeneration.  —  Usually  extensive 
oedema,  accompanied  by  a  large  amount  of  albumin.  The 
quantity  of  urine  varies.  The  urinary  sediment  is  charac- 
teristic and  contains  globules  of  fatty  granules,  granular  and 
often  waxy  casts,  and  much  epithelium.  The  disease  is 
usually  fatal  in  from  one  to  two  years,  in  an  attack  of  urse- 


IX  THE   DISEASES   OE   THE    KIDNEYS  223 

mia  or  through  compHcations  (rupture  of  the  oedematous 
skin  and  erysipelas,  pneumonia,  etc.). 

Primary  atrophic  kidney.  —  Abundant  urine  of  low  specific 
gravity,  greenish-yellow  of  color,  with  little  albumin,  very 
little  or  no  sediment.  Hypertropliy  of  the  heart,  pulse  of 
very  high  tension,  retinitis  frequent;  begins  insidiously 
and  often  develops  very  slowl}-.  It  occurs  in  general  arterio- 
sclerosis (arterio-capillary  fibrosis),  in  gout,  and  in  plumbism 
(uric  acid  kidney). 

The  atrophic  kidney  may  also  develop  from  a  previous  nephritis 
of  long  standing  or  from  a  puerperal  nephritis.  Rarely,  it  may 
arise  from  chronic  congested  kidne}'.  The  development  of  a 
secondary  atrophic  kidney  from  a  chronic  parench3'matous  nephri- 
tis is  exceedingly  rare. 

Chronic  congestion  of  the  kidney  presents  oedema,  chiefly 
in  the  legs,  cyanosis,  and  dyspnoea.  There  is  a  coexisting 
cardiac  or  pulmonary  affection.  The  urine,  scanty  and 
dark-colored,  is  of  a  high  specific  gravity.  It  shows  the 
brick-dust  deposit  (sediment urn  lateritium),  and  contains  but 
little  albumin. 

Amyloid  degeneration  of  the  kidney  proceeds  generally 
with  the  symptoms  of  a  chronic  nephritis.  The  proof  of  the 
etiological  factor  is  necessary  to  a  diagnosis  (see  ''history"), 
as  is  also  the  simultaneous  enlargement  of  the  liver  and 
spleen. 

The  other  diseases  of  the  kidney  are  not  accompanied 
with  oedema,  but  often  Avith  changes  occurring  in  the  urine. 
They  are  recognized  partly  by  these  features  and  partly  by 
the  occurrence  of  pains  in  the  region  of  the  kidneys,  by 
palpation  and  percussion  of  the  abdomen  and  especially  of 
the  renal  region. 

The  following  are  chiefly  to  be  considered :  hsemorrhagic 
infarction  of  the  liver,  pyelonephritis,  renal  calculi,  renal 
tuberculosis,  tumors  of  the  kidney,  and  movable  kidney. 


224  THE    DISEASES   OF   THE   KIDNEYS  chap. 

Pains  in  the  region  of  the  kidneys  (in  the  loins)  appear  so  fre- 
quently in  entirely  different  diseases  that  this  symptom  should  be 
used  only  with  reserve  in  making  a  diagnosis  of  kidney  disease. 
Paroxysmal  severe  pain  (renal  colic)  is  the  sign  of  the  presence  of 
renal  calculi. 


Situation  of  the  Kidneys,  Percussion 

The  kidneys  lie  between  the  12th  dorsal  and  3d  lumbar  verte- 
brae. The  right  kidney  reaches  to  the  liver  above,  the  left  to  the 
spleen. 

The  object  of  percussion  of  the  renal  region  is  to  locate  the 
lower  and  outer  borders  of  the  kidneys ;  however,  the  results  of  this 
are  not  entirely  reliable,  on  account  of  the  large  fat  accumulation 
which  sometimes  envelops  the  capsule  of  the  kidneys  and  on 
account  of  the  varying  condition  of  the  intestines  as  to  solid  con- 
tents. 

Marked  increase  of  renal  dulness  occurs  when  the  kidney  is  en- 
larged by  the  development  of  a  tumor  of  the  organ  (see  below)  ; 
the  entire  absence  of  renal  dulness  justifies  the  conclusion  that  a 
movable  kidney  (floating  kidney)  is  present,  which  is  found  much 
more  frequently  on  the  right  side  than  on  the  left. 


Chief    Symptoms  of    a   Few  of   the    Non-diffuse  Dis- 
eases OF  THE  Kidneys 

Haemorrhagic  infarct  of  the  kidney  is  characterized  by  the 
sudden  appearance  of  Junmatiiria;  pain  in  the  region  of  the 
kidney  and  a  slight  rise  in  temperature.  The  diagnosis  is 
aided  by  the  proof  of  the  etiological  factor,  an  embolism  due 
to  a  valvular  defect  or  cardiac  dilatation.  The  haematuria 
disappears  quickly. 

Suppurative  nephritis  (  pyelonephritis).  —  There  is  an  irreg- 
ular remittent  type  of  fever  associated  with  chills  ;  the  uri- 
nary sediment  contains  pure  pus,  usually  without  casts ; 
there  is  blood  in  the  urine  only  when  the  pyelonephritis 
has  lieen  caused  by  trauma  or  renal  calculus.  Severe  pain 
in  the  renal  region  is  frequent. 


IX  THE   DISEASES   OF   THE    KIDNEYS  225 

Tumor  of  the  kidney  is  determined  by  palpation,  bimanual 
palpation  being-  (jften  necessary ;  it  is  often  very  difficult  to 
determine  the  renal  origin  of  the  tumor,  the  diagnosis  being 
aided  by  the  immobility  of  the  tumor  on  forced  respiration, 
the  constriction  of  the  colon,  in  certain  cases  by  the  super- 
position of  the  distended  k,rge  intestine  over  the  tumor,  and 
the  increased  area  of  renal  dulness. 

We  must  decide  differentially  between  an  echinococcus 
(positively  determined  when  the  booklets  or  the  cyst  wall  is 
found  in  the  fluid  aspirated  from  the  tumor),  hydronephrosis 
(determined  by  the  intermittent  filling  and  emptying  of  the 
fluctuating  sac  and  by  the  x^resence  of  urea  in  the  fluid 
gained  by  aspiration),  and  carcinoma  and  sarcoma  (they  are 
solid  tumors  and  are  accompanied  by  a  rapidly  progressing 
cachexia). 

Renal  calculi  (nephrolithiasis)  is  characterized  by  attacks 
of  renal  colic  which  terminate  with  the  passage  of  the  con- 
cretion; by  the  excretion  of  sediment  independent  of  the 
attack  of  colic,  the  sediment  being  chiefly  composed  of 
phosphates  or  urates ;  by  the  frequent  occurrence  of  hsema- 
turia.  The  reaction  of  the  urine  varies  according  to  the 
nature  of  the  calculi. 

Movable  kidney.  —  On  palpation  a  movable  abdominal 
tumor  of  the  shape  of  the  kidney  is  felt.  The  area  of  kid- 
ney dulness  is  obliterated.  There  are  numerous  nervous 
complaints,  the  patient  complaining  especially  of  traction 
and  weight  in  the  abdomen. 


Bladder  diseases  present  for  diagnosis  these  conspicuous 
forms :  — 

Cystitis,  which  is  diagnosed  by  the  presence  of  frequent, 

painful   vesical  tenesmus,  associated  with  the  voiding  of 

dirty  cloudy  urine  full  of  pus  cells  and  frequently  the  seat 

of  ammoniacal  decomposition  (see  pp.  185  and  212).     The 

Q 


226  THE   DISEASES   OF  THE   KIDNEYS  chap. 

cause  of  the  cystitis  must  be  determined  (gonorrhoea,  ure- 
thral stricture,  hypertrophy  of  the  prostate,  stone  in  the 
bladder,  2Kiralysis  of  the  bladder  from  spinal  cord  disease).  In 
acute  cystitis  (the  result  of  exposure  or  of  gonorrhoea)  the 
urine  is  scanty,  cloudy,  acid  in  reaction,  bloody,  and  there  is 
intense  local  pain  and  spasm. 

Stone  in  the  bladder  is  diagnosed  by  the  presence  of  fre- 
quent haematuria  without  a  characteristic  sediment,  disturb- 
ances in  passing  urine,  in  many  cases  an  accompanying 
cystitis  and  pains  which  radiate  to  the  end  of  the  penis. 
The  diagnosis  is  only  positively  made  by  sounding  the 
bladder. 

Tumors  of  the  bladder  (papilloma  [papillomatous  fibroma, 
villous  disease]  and  carcinoma)  are  diagnosed  by  the  occur- 
rence of  attacks  of  pain  and  haemorrhages  in  the  bladder, 
and  by  the  presence  of  a  chronic  cystitis.  The  diagnosis  is 
only  established  where  a  tumor  can  be  felt  by  a  digital 
examination  in  the  rectum  or  vagina,  or  by  the  catheter 
introduced  into  the  bladder,  or  where  particles  of  the  tumor 
can  be  demonstrated  to  exist  in  the  urine.  Finally  the 
endoscope  or  cystoscope  may  show  the  presence  of  a  growth. 


The  Examtnation  of  E-exal  axd  Vesical  Calculi 

We  distinguished  between:  1.  Uric  acid  calculi,  which  are 
most  frequent  in  occurrence ;  they  are  hard,  their  ^surface  is 
smooth  or  only  a  little  nodular,  their  color  varies  from  a 
yellow  to  a  reddish-brown.  Calculi  composed  of  ammo- 
nium urate  are  brittle,  and  of  a  dirty  grayish-yellow  color. 
2.  Oxalate  of  lime  calculi  (mulberry  calculi)  are  very  hard, 
they  have  a  rough  warty  surface,  and  vary  in  color  from 
brown  to  black.  ?>.  Phosphatic  calculi  (composed  of  cal- 
cium phosyjhate  and  of  ammonio-magnesium  phosphates) 
are  soft  and  easily  pulverized ;  their  surface  is  sandy  and 


IX  THE   DISEASES   OF   THE    KIDNEYS  227 

rough,  often  glistening ;  their  color  is  usually  white.  4.  Cal- 
culi formed  of  the  carbonates  are  hard,  like  chalk,  with  a 
smooth  surface  and  of  a  white  color.  5.  Cystiri  calculi 
are  as  a  rule  small,  tolerably  hard,  smooth,  and  yellowish. 
6.  XantJun  calculi  are  quite  hard,  of  a  cinnamon-brown 
color,  and  their  surface  when  rubbed  glistens  like  wax. 

Frequently  the  concretion  or  stone  is  not  composed  of  one 
material  alone,  but  the  nucleus  may  be  composed  of  one 
chemical  compound  and  the  body  of  the  calculus  of  another. 

Their  composition  is  determined  by  a  chemical  analysis 
like  the  follawing,  which  is  recommended  by  Salkowski. 

It  is  advisable  for  conducting  the  analysis  to  determine  whether 
the  calcuhis  is  composed  of  organic  or  of  inorganic  materials.  If 
it  be  of  an  organic  compound,  the  calculus  when  pulverized  will 
be  completely  consumed  when  heated  in  a  platinum  capsule  or 
it  leaves  but  a  very  little  ash  residue.  In  this  case  the  calculus 
is  composed  of  uric  acid,  of  ammonium  urate,  of  cystin,  or  of 
xanthin.  Should  an  ash  residue  be  left  after  heating,  the  cal- 
culus may  be  composed  of  urates,  phosphates,  or  oxalates. 

I.  The  Uric  Acid  Calculus  is  Completely  Consumed  by  Heat 

The  powdered  calculus  is  digested  with  a  weak  solution  of 
hydrochloric  acid  and  gentle  heat. 

a.  The  portion  of  powdered  calculus  used  will  either  be  dis- 
solved completely  or  for  the  greatest  part ;  in  this  case  the  calculus 
is  composed  of  cystin  or  xanthin.  Cj/stin  will  be  dissolved  by 
ammonia  and  will  crystallize  after  the  evaporation  of  the  solution 
into  hexagonal  crystals. 

Xanihin  is  tested  by  dissolving  a  portion  of  the  powdered  calcu- 
lus in  a  porcelain  dish  with  some  nitric  acid  and  slowly  evaporat- 
ing the  mixture.  If  xanthin  l^e  present,  a  lemon-yellow  residue 
will  be  left  which  is  not  solul)le  in  ammonia,  but  which  will  change 
to  a  reddish-yellow  on  the  addition  of  some  potassium  hydrate. 

b.  Or  the  portion  used  will  not  be  dissolved  completely,  in 
which  case  the  solution  is  filtered,  and  the  filtrate  is  tested  for 
uric  acid  by  the  murexide  test ;  the  filtrate  may  contain  ammonium 
chloride,  which  may  be  tested  by  adding  some  sodium  bicarbonate 
and   heating   the   mixture,  when   the   odor   of    ammonia  will  be 


228  THE   DISEASES   OF  THE    KIDNEYS  chap,  ix 

detected ;  or  some  moistened  red  litmus  paper  may  be  held  over 
the  dish  containing  the  mixture  and  the  red  litmus  paper  will 
become  blue ;  or  a  glass  rod  dipped  into  hydrochloric  acid  may  be 
held  over  the  dish  and  a  cloud  will  form  above  the  dish  about 
the  rod. 

IT.  The  Calculus  may  turn  Black,  but  may  not  be  Consumed 

Another  portion  of  the  pulverized  stone  is  digested  with  some 
weak  hydrochloric  acid  and  exposed  to  heat.  Should  the  powdered 
stone  effervesce,  it  contains  a  carbonate. 

a.  Complete  solution  of  the  contents  of  the  dish  denotes  an 
absence  of  uric  acid. 

b.  Incomplete  solution  denotes  that  the  residue  may  contain 
uric  acid  or  an  albuminoid  substance.  This  may  be  determined 
by  the  murexide  test. 

The  filtered  solution  is  rendered  slightly  alkaline  by  the  addition 
of  ammonia;  it  is  then  rendered  slightly  acid  again  with  acetic 
acid.  Should  a  white  powdery  precipitate  form,  it  denotes  the 
presence  of  oxalate  of  lime.  This  is  removed  by  filtration,  and  the 
filtered  solution  should  be  tested  for  phosphoric  acid,  for  calcium, 
and  magnesium.  A  portion  of  the  filtered  solution  is  mixed  with 
some  ferric  chloride,  which,  if  phosphoric  acid  be  present,  will 
produce  a  grayish-white  precipitate.  The  chief  remnant  of  the 
filtered  solution  sliould  then  be  mixed  with  ammonium  oxalate, 
whereupon  a  precipitate  being  formed  would  denote  the  presence 
of  magnesia.  The  lime  is  removed  by  filtration  and  to  the  filtered 
sohition  some  of  a  solution  of  sodium  phosphate  is  added  and  the 
whole  subjected  to  heat.  It  is  then  rendered  alkaline  with  ammo- 
nia. A  slowly  developing  crystallizing  deposit  will  indicate  the 
presence  of  magnesia. 


CHAPTER   X 

THE   DIAGNOSIS   OF   THE   DISORDERS   OF   METABOLISM 
Laws  of  ISTokmal   ^Ietabolic  Processes 

The  human  body  requires  the  ingestion  of  food  material 
in  order  that,  on  the  one  hand,  it  may  conduct  its  vital  func- 
tions undisturbed,  and  on  the  other  hand,  that  it  may  not 
coDSume  the  essential  constituents  of  its  own  tissues,  which 
consist  of  the  albuminoids,  fats,  carbohydrates,  water,  and 
inorganic  salts. 

The  products  of  the  disintegration  of  the  albuminoids  are 
excreted  by  the  urine  as  urea,  uric  acid,  etc. ;  the  fats  and 
carbohydrates  are  oxidized  into  carbonic  acid  and  removed 
from  the  body  in  the  breath,  but  they  are  nevertheless  of 
great  importance  in  the  preservation  of  the  organism. 

The  albuminoids  are  very  complex  bodies,  whose  chemical  com- 
position has  not  as  jet  been  sufficiently  investigated ;  only  this 
much  is  known,  that  from  the  disintegration  of  albunnn  occurring 
in  the  body  different  chemical  groups  are  formed,  viz. :  (1)  a  nitro- 
genous, urea-like  group,  which  is  excreted  in  the  urine ;  (2)  an 
aromatic  group  containing  or  represented  by  Cj^H-  which  is  like- 
wise excreted  in  the  urine ;  (3)  a  group  resembling  the  fats,  and 
which  further  act  like  fats  and  carbohydrates  and  are  removed  from 
the  body  by  the  breath  as  CO2.  In  this  way  the  positive  fact  is 
explained  that  fat  and  sugar  can  he  formed  in  the  hody  from  the  albu- 
7nins,  and  that  albumin,  when  introduced  in  sufficient  quantity, 
can  replace  the  other  nutritive  materials.  On  the  other  hand,  the 
fats  and  carbohydrates,  which  lack  the  nitrogenous  and  aromatic 
compounds,  can  only  replace  the  albumin  to  a  limited  extent, 

229 


230  THE    DISORDERS   OF   METABOLISM  chap. 

The  requisite  amount  of  food-stuffs. — In  order  that  the 
nutrition  of  the  body  may  be  kept  at  the  normal,  it  requires 
that  the  body  be  given  a  certain  amount  of  food.  In  order 
that  in  estimating  the  amount  of  nourishment  needed,  a  uni- 
form measure  may  be  used  for  the  different  food-stuffs,  we 
make  use  of  the  amount  of  heat  which  is  developed  from  the 
disintegration  of  food,  and  which  has  been  used  by  differ- 
ent investigators  in  their  experiments  and  investigations. 
Therefore  as  the  unit  value  we  make  use  of  the  calorie, 
Avhich  is  that  amount  or  quantity  of  heat  which  is  necessary 
to  raise  one  kilogramme  of  water  one  degree  in  temperature. 

We  may  therefore  substitute  for  the  amount  of  food-stuff 
its  corresponding  value  in  calorics,  in  this  manner :  — 

1  g.  albumin  =4.1  calories 

1  g.  fat  =  9.3  calories 

1  g.  carbohydrate  =  4.1  calories 
1  g.  alcohol  =  7.0  calories 

Instead  of  saying  a  strong  man  needs  for  nom-ishment  118  g. 
of  albumin,  56  g.  of  fat,  and  500  g.  of  carbohydrates,  we  may  say 
he  needs  the  equivalent  of  3051.6  calories. 

The  number  of  calories  which  are  needed  for  nourishment 
by  a  healthy  man  depends  on  his  body  weight,  on  the 
amount  of  work  performed  by  him,  and  on  his  previous 
condition  of  nutrition.  A  healthy,  strong  laborer  weighing 
about  70  kg.  requires  daily  about  3000  calories,  and  when 
doing  work  requiring  the  exercise  of  additional  effort,  the 
necessary  number  of  calories  will  rise  to  between  4000  and 
5000;  a  less  strong  laborer,  whose  weight  is  about  50  kg., 
requires  about  2400  calories.  The  requisite  amount  there- 
fore for  a  healthy  man  is  about  45  calories  for  every  kilo- 
gramme of  weight.  However,  it  is  entirely  improper,  if  we 
wish  to  determine  the  amount  of  nourishment  needed  by  a 
healthy  man,  to  simply  multiply  his  body  weight  by  a  cer- 


X  THE   DISORDERS   OF   METABOLISM  231 

tain  number  of  calories.  Moreover,  the  necessary  number 
of  calories  necessary  for  his  sustenance  depends  essentially 
on  the  condition  of  the  physical  changes  of  the  days  imme- 
diately preceding.  For  instance,  if  a  man,  otherwise  nor- 
mal, have  an  oesophageal  stricture  of  long  standing  Avhich 
has  left  him  badly  nourished,  and  by  reason  of  this  much 
emaciated,  he  may  retain  the  condition  in  which  he  is  at 
the  time,  even  with  from  1000  to  1500  calories,  yes,  even 
with  less.  To  estimate  the  number  of  calories  necessary,  it 
is  essential  to  study  in  each  individual  case  the  nutrition  of 
the  body  and  conditions  of  the  preceding  days. 

Relations  of  the  food-stuffs  to  each  other.  —  It  is  yery 
essential  to  observe  in  nutrition  that  the  representation  of 
the  various  food-stuffs  corresponding  to  their  caloric  yalues 
is  only  possible  up  to  certain  limits.  It  is,  moreover,  neces- 
sary that  a  definite  amount  of  albumin  be  always  admin- 
istered to  the  body;  this  can  not  be  replciced  by  fats  and 
carbohydrates.  The  quantity  of  this  necessary  amount  of 
albumin  (cdbumin  necessary  to  nutrition)  depends  upon  the 
condition  of  nutrition,  rather  on  the  store  of  albumin  in  the 
body,  and,  on  the  other  hand,  upon  the  amount  of  carbo- 
hydrates and  fats  which  haye  at  the  same  time  been 
administered. 

The  amount  of  albumin  necessary  for  the  nutrition  of  a 
strong,  well-nourished  man  is  from  80  to  100  g. ;  in  the 
poorly  nourished  and  in  the  non-worker  it  may  be  less. 

It  is  only  when  the  amount  of  albumin  necessary  for 
the  body's  nutrition  has  been  reached,  that  the  food-stuft's 
may  be  reckoned  entirely  according  to  their  corresponding 
caloric  values ;  and  it  depends  more  upon  the  condition  of 
the  stomach  and  the  digestion  whether  fats  and  carbo- 
hydrates or  whether  more  albumin  should  be  giyen. 

Before  the  po^Yer  of  substitution  of  one  food  for  another,  by 
virtue  of  the  measurement  of  its  calories,  was  sharply  defined,  it 
was  known  that  the  various  foods  could  replace  each  other  under 


232  THE   DISORDERS   OF   METABOLISM  chap. 

certain  conditions ;  these  were  called  isodynams.  Thus  100  g.  of 
fat  equalled  211  g.  of  albumin,  or  232  g.  of  starch,  or  234  g.  of 
cane-sugar,  or  256  g.  of  grape-sugar. 

Exchange  of  food-stuffs.  —  The  transposal  of  the  albumin 
depends  upon  the  amount  of  nourishment  taken,  and  as 
well,  indeed,  upon  the  number  of  its  calories  and  upon  the 
amount  of  albumin  taken  in  the  food.  If  less  albumin  is 
administered,  where  there  is  a  sufficient  number  of  calories, 
than  is  contained  in  the  albumin  needed  for  nutrition,  then 
more  nitrogen  is  excreted  in  the  urine  than  is  contained  in 
the  food  (1  g.  of  N  corresponds  to  6.25  g.  of  albumin). 
Should  albumin  be  contained  in  the  food  given  to  cases 
where  the  total  number  of  calories  is  sufficient,  then  an 
equilibrium  is  formed  in  the  nitrogenous  production,  that  is, 
the  excreted  N  is  equal  to  the  amount  of  N  administered. 
Should  more  albumin  than  is  necessary  be  administered,  in 
cases  where  the  total  number  of  calories  is  sufficient,  then 
more  N  is  excreted,  and  the  equilibrium  as  far  as  N  is  con- 
cerned is  soon  reestablished. 

Considerable  proteid  increase  can  be  attained  only  in  a  person 
in  the  process  of  growth,  in  cases  of  convalescence  from  an  acute 
disease,  and  in  simple  inanition. 

If  the  total  number  of  calories  contained  in  the  food  is 
not  sufficient,  an  increase  of  the  excretion  of  nitrogen  may 
take  place  even  in  cases  where  sufficient  albumin  has  been 
taken  as  food. 

Again,  the  albuminous  exchange  depends  upon  the  pre- 
vious nutrition  and  the  condition  of  the  body  produced  by 
that  nutrition.  Muscular  people  having  plenty  of  albumin 
consume  more  allmmin  than  fat  people  in  whom  the  ex- 
change of  albumin  is  less. 

Work  has  no  influence  on  the  consumption  of  albumin  in 
general ;  ))iit  it  favors  the  consumption  of  fats  and  carbo- 
hydrates.    Should  not  sufficient  fats  and  carbohydrates  be 


X  THE   DISORDERS   OF   METABOLISM  233 

administered  in  food,  the  body  will  then  consume  its  own 
fat,  in  order  that  the  necessary  work  may  be  done. 

However,  everything  in  such  cases  depends  upon  the  total  num- 
ber of  calories;  if  it  be  very  large,  the  contribution  to  the  amount 
needed  for  work,  where  there  has  been  no  fat  or  carbohydrates 
adiuinistered,  is  made  good  in  part  by  tlie  metabolism  of  the 
albumin  itself  into  the  fat  groups;  and  if  the  number  of  caloiies 
be  insufficient,  then  both  the  fat  as  well  as  the  albumin  of  the 
body  are  consumed. 

Anomalies  of  Metabolism 

The  anomalies  of  metabolism  thus  far  known  consist  of :  — 

1.  Qualitative  changes  by  which  the  urine  will  contain 
substances  Avhich  are  not  excreted  in  it  in  health. 

The  most  important  qualitative  changes  occur  in  diabetes 
mellitus,  where  grape-sugar  appears  in  the  urine,  while  in 
health  all  the  carbohydrates  are  transformed  in  the  organ- 
ism into  CO2. 

Certain  forms  of  obesity  seemingly  depend  upon  the  loss  of  the 
power  to  oxidize  the  fat  formed  in  the  body. 

In  some  rare  forms  of  disordered  jnetabolism,  which  are  not  yet 
sufficiently  known,  some  extremely  peculiar  substances  are  excreted 
in  the  urine;  for  example,  cystin  and  diamine  in  cases  of  cysturia. 

2.  Quantitative  changes.  These  are  chiefly  shown  in  the 
metabolism  of  the  albuminoids.  The  laws  of  the  equilib- 
rium of  N  where  the  income  is  sufficient,  which  were  men- 
tioned in  the  previous  paragraphs,  suffer  in  a  few  diseases 
an  alteration  in  the  shape  of  a  more  extensive  transforma- 
tion :  an  increased  consumption  of  albumin,  a  more  marked 
oxidation  of  the  albuminoids  of  the  body  takes  place.  This 
is  noticed  in  fever,  in  many  cases  of  phthisis,  in  carcinoma, 
in  anaemia,  and  in  leucaemia. 

A  diminution  of  proteid  metabolism  occurs  in  cases  of  convales- 
cence from  acute  disease,  in  inanition,  in  many  forms  of  obesity, 
and  in  myxoedema. 


234  THE   DISORDERS   OF   METABOLISM  chap. 

The  conditions  of  diminished  excretions  as  a  result  of  disease  of 
excreting  organs,  as,  for  example,  the  diminution  of  the  excretion 
of  urea  in  nephritis,  belong  to  the  disturbances  of  metabolisui  in 
the  broader  sense.  The  diseases  of  the  pancreas,  liver,  and  intes- 
tines ought  to  be  here  mentioned ;  in  these  conditions  less  fat  and 
albumin  are  absorbed  in  the  intestine  than  under  normal  condi- 
tions of  the  organs. 

In  gout  it  would  appear  that  the  question  is  one  of  an  increased 
production  of  uric  acid  from  an  increased  destruction  of  nuclein 
(see  p.  206)  ;  the  excess  of  uric  acid  in  the  blood  can  be  partly 
accounted  for  by  inflamed  and  necrotic  areas  of  tissue  (gout 
necrosis).      * 

In  order  to  diagnose  a  disturbance  of  metabolism  with 
certainty,  it  is  necessary  to  tabulate  the  income  and  the 
expenditure  as  in  a  balance-sheet.  Clinically,  the  determi- 
nation of  the  following  data  is  sufficient :  — 

1.  The  value  of  the  food. 

2.  The  constituents  of  the  urine  (N,  sometimes  uric  acid, 

finally  sugar). 

3.  The  unahsorhed  portion  of  food  in  the  faeces,  determined 

by  the  amount  of  N  and  fat  contained  therein. 

By  determining  these  points  the  metabolism  of  the  albu- 
minoids can  be  accurately  accounted  for ;  the  metabolism  of 
the  fats  and  carbohydrates  will  escape  a  quantitative  esti- 
mation if  the  amount  of  carbonic  acid  in  the  breath  be  not 
measured. 

1.    The  Value  of  the  Food 

In  order  to  accurately  determine  this,  it  is  necessary  that  every- 
thing which  the  patient  eats  should  be  weighed  by  the  scales  and 
what  is  left  uneaten  should  be  deducted.  The  value  of  the  differ- 
ent articles  of  food  in  nutritive  materials  is  cleared  up  by  the  fol- 
lowing table:  — 


THE   DISORDERS   OF   METABOLISM 


235 


Akticles  of  Food 

MIN 

Vkr 

Cent. 

N 
Pkii 

Cent. 

Fat 
Peh 

Cent. 

Cahho- 
nv- 

IIKATES 
I*EK 

Cent. 

Analysis 

.MAKE    HV 

Raw  beef,    free    from 

visible  fat  .... 

18.36 

3.4 

0.9 

Voit. 

Moderately  fat^ 

20.91 

3.3 

5.19 

0.48 

König. 

Fat,  uncooked    p.     ,. 

17.19 

2.8 

26.38 

König. 

Roast 

30.56 

4.89 

6.78 

Rubner. 

Boiled              J 

21.8 

3.5 

4.52 

Renk. 

^.^^^Hveal.     .     .     . 
Raw   ) 

18.88 
15.3 

3.02 

2.84 

7.41 
5.2 

0.071 

König. 
Renk. 

One  egg  (45  g.  Avithout 

shell) 

6.25  g. 

Ig.N 

4.9  g. 

Voit. 

Good  milk     .... 

4.13 

0.64 

3.9 

4.2 

Voit. 

Milk  (for  children) 

(Charite)    .... 

3.88 

0.62 

3.1 

4.5 

The  author. 

Skimmed  milk    .     .     . 

3.25 

0.52 

1.1 

4.1 

The  author. 

Butter 

0.5 

0.08 

87.0 

0.5 

König. 

Cheese 

32.2 

4.75 

26.6 

2.97 

Renk. 

Bacon  (Charit^)      .     . 

94.7 

The  author. 

White  bread  (rolls)     . 

9.6 

1.5 

1.0 

60.0 

Renk. 

Rye  bread,  fresh     .     . 

5.63 

0.9 

44.0 

The  author. 

Bread  (Charit^).     .     . 

8.22 

1.315 

0.64 

58.3 

The  author. 

Boiled  potatoes,  with- 

out the  skins  . 

2.18 

0.35 

23.0 

Rubner. 

Vegetables    (Charite) 

from  3  analyses  .     . 

3.45 

0.55 

4.2 

20.3 

The  author. 

Soup  (Charite)  from  3 

analyses     .... 

1.7 

0.272 

1.8 

8.3 

The  author. 

Beer  (light)   .... 

0.56 

0.09 

5.5 

The  author. 

Wine 

0.19 

0.03 

2.0 

König. 

Coffee  (weak)     .     .     . 

0.25 

0.04 

The  author. 

2.    The  Constituents  of  the  Urine 

It  is  of  prime  importance  to  collect  the  urine  passed  in  the  24 
hours,  without  loss.  The  total  amount  of  nitrogen  contained 
therein  is  then  determined  according  to  the  rules  given  on  p.  206. 


236 


THE   DISORDERS   OF   METABOLISM 


CHAP. 


In  diabetes  a  quantitative  analysis  of  the  sugar  passed  must   be 
made  (p.  196). 

3.    The  Undigested  Nitrogenous    Materials   and   Fats   left    in 

the  Faeces 

The  faeces  passed  on  the  day  are  marked  by  previously  adminis- 
tering some  of  a  black  coloring  charcoal  mixture.  The  faeces  are 
dried  ;  the  nitrogen  in  them  is  determined  by  the  method  of  Kjel- 
(lahl,  and  the  fat  by  extracting  with  ether. 

It  is  customary  to  add  the  N  in  the  faeces  to  the  N  in  the  urine 
and  to  record  in  the  table  under  food  the  added  figure  as  the 
expenditure. 

The  estimation  of  the  amount  in  the  fseces  is  both  tedious 
and  laborious  ;  we  can  not  do  without  it  in  some  cases.  For 
clinical  purposes  the  values  formed  by  Rubner  as  represent- 
ing the  consumption  of  food  in  the  intestines  may  be  used 
with  advantage. 


Abticle  of  Food 


Meat  .  .  . 
Eggs  .  .  . 
Milk  .  .  . 
Wheat  bread 
Rye  bread  . 
Potatoes 
Vegetables  . 


N 
Per  Cent. 


2.65 
2.9 
8.9 
20.7 
32.0 
32.2 
18.5 


Fat 
Per  Cent. 


19.2 
5.0 

5.7 


6.1 


Carbohydrates 
Per  Cext. 


1.1 
19.9 

7.6 
15.4 


These  values  may  only  be  used  when  a  good-sized  movement 
from  the  bowels  occurs  regularly ;  in  many  diseases  associated  with 
diarrhoea  this  consumption  suffers  to  a  great  extent.  That  of  fat 
is  much  affected  in  icterus  and  atrophy  of  the  pancreas,  in  severe 
ansemias,  and  in  most  diarrhoeal  diseases. 

From  the  values  obtained  a  metabolic  balance-sheet  is  made 
something  like  the  following :  — 


THE   DISORDERS   OF   METABOLISM 


237 


DISEASE  :  CARCINOMA  OF  THE  STOMACH  (AGE,  49  YEARS) 

Income 


Date 

Body 
Wkigiit, 
Pounds 

Nourishment 

N 

Fat 

Carbo- 
hydrates 

Calories 

I. 

12 

115 

1500  g.  milk 
85  g.  bread 
40  g.  butter 
4  eggs 

7.8 
1.1 

16.5 
0.54 

34  8 
19.6 

61.5 
49.5 

4.0 

Total 

12.9 

71.4 

111.0 

1474 

I. 

13 

115 

2000  g.  milk 
110  g.  bread 
40  g.  butter 
4  eggs 

12.4 
1.4 

22.0 
0.7 

34.8 
19.6 

82.0 
64.0 

4.0 



Total 

Average 

17.8 
15.:35 

77.1 

146.0 

1763 
1618.5 

Expenditure 


UUINE 

F^CES 

N 

Total 

Amount 

Sp.  Gr. 

N 

Moist 

Dry 

N 

I. 

12 
I. 

13 

1350 
1750 

1022 
1015 

21.6 
23.4 

[317 

87.2 

2.66 

22.6 
24.4 

Tota 
Avei 

1    .     .     . 

47.0 

'ace    . 

23.5 

Therefore  the  daily  average  is  :  — 

Nitrogen  income  =  15.35 

Nitrogen  expenditure  =  23.5 

And  the  daily  expenditure  of  8.2  N  =  241.1  g.  of  muscle  tissue. 


238 


THE   DISORDERS   OF    METABOLISM 


CHAP. 


In  this  balance-sheet  it  is  often  necessary  to  estimate  the  N  in 
reference  to  urea,  or  to  albumin,  or  to  muscle  tissue.  To  render 
this  estimate  easy,  the  constant  relations  existing  between  them 
are  here  mentioned  :  — 


Nitrogen 

Urea          : 

2.143 

Xitrogen 

Albumin 

6.25 

Nitrogen 

^Muscle  tissue  : 

29.4 

Urea 

Nitrogen      : 

0.466 

Urea 

Albumin 

2.9 

Urea 

Muscle  tissue  : 

13.71 

The  differential  diagnosis  of  proteid  metabolism  is  only  called 
for  in  some  special  rare  instances,  as,  for  instance,  in  determining 
the  malignant  or  benign  nature  of  tumors. 

The  significance  of  these  metabolic  balance-sheets  lies  chiefly  in 
the  possibility  of  controlling  by  their  study  the  nutrition  of  the 
patient  to  the  most  exact  degree,  and  of  always  harmonizing  the  diet 
with  each  state  of  nutrition  and  body  change. 

In  diabetes  mellitus  the  constant  attention  j^aid  to  me- 
tabolism is  of  immediate  significance  in  diagnosis  and  in 
treatment.  T^vo  varieties  of  this  form  of  diabetes  are 
recognized,  either  of  which  may  become  converted  into  the 
other :  — 

1.  The  mild  form,  in  which  sugar  only  appears  in  the 

urine  after  the  ingestion  of  carhohydrates;  the  sugar 
excretion  is  larger  or  smaller  according  as  the 
amount  of  carbohydrates  ingested  is  greater  or 
less. 

2.  The  severe  form,  in  which  sugar  is  contained  in  the 

urine  even  after  many  days  have  passed  in  which 
no  carhohydrates  at  all  have  been  taken  as  food. 

Only  a  carefully  prepared  metabolic  balance-sheet  will 
give  an  accurate  knowledge  of  diabetics  and  their  treat- 
ment. 


As  an  example,  I  give  a  .balance-sheet  of  a  mild  case  of  dia- 
betes. 


THE   BISORDERS   OF   METABOLISM 


239 


Income 


Date 

I  Join- 
Weight  in 

POUNDH 

Nourishment 

N 

Fat 

C!akho- 
iiydkates 

Caloeies 

III. 
15 

115 

1  litre  milk 
10  eggs 
120  g.  butter 
125  g.  meat 
CO  g.  bread 

6.2 
10.5 

31.0 

49.0 

104.4 

1.1 

0.4 

45.0 

4.2 

0.8 

35.0 

Tot 

al 

21.2 

185.9 

80.0 

2600 

Expenditure 


Date 

IIkine 

F^CES 

N 

Total 

Amount 

Sp.  Gr. 

N 

Sugar 

Moist 

Dry 

N 

III. 

15 

2800 

1022 

18.8 

33.6 

(1-2  %) 

238 

47.6 

1.7 

20.5 

Therefore  of  80  g.  of  carbohydrates,  46.4  g.  are  consumed  regu- 
larly, and  33.6  g.  are  excreted  in  the  urine  unconsumed.  The 
excretion  of  nitrogen  is  somewhat  less  than  the  amount  taken  in. 


Symptoms  of  a  Few  of  the  Metabolic  Disorders 

Diabetes  mellitus.  —  The  diagnosis  is  settled  by  a  positive 
reaction  to  the  test  for  sugar.  It  depends  whether  an  ex- 
amination of  the  urine  is  thought  of  at  the  right  time.  The 
following  signs  should  induce  the  physician  to  make  a  uri- 
nary examination  for  sugar :  diminution  of  physical  and 
mental  capacity,  progressive  cachexia,  very  much  increased 
appetite  (polyphagia),  much  increased  thirst  (polydipsia), 
large  excretion  of  urine  (polyuria) ;  in  certain  cases  there 


240  THE   DISORDERS   OF   METABOLISM  chap,  x 

is  a  tendency  to  the  production  of  boils  (furunculosis), 
simple  wounds  heal  with  difficulty,  severe  pruritus  is  present, 
the  presence  of  certain  diseases  of  the  eye  (cataract,  optic 
neuritis),  and  an  early  development  of  impotence  occurs. 
Concerning  the  mild  and  severe  forms,  see  p.  238 :  ferric 
chloride  reaction,  p.  200. 

Gout  is  characterized  by  repeated  short  attacks  of  inflam- 
mation of  the  joints,  especially  of  the  metatarso-phalangeal 
joint  of  the  large  toe,  although  it  also  occurs  in  other  joints. 
After  the  attacks  deposits  of  uric  acid  often  accumulate  in 
the  cartilages  of  the  joint  (gout  nodules,  tophi).  Tophi  also 
are  deposited  in  the  cartilage  of  the  ear  and  in  the  skin, 
especially  of  the  leg.  After  frequent  attacks  deformities  of 
the  joints  ensue.  Interstitial  nephritis  and  atrophic  kidney 
(gout  of  the  kidneys)  often  develop.  In  the  intervals 
between  the  attacks  there  are  many  nervous  disturbances 
(intervallary  symptoms)  and  often  inflammatory  affections 
of  the  internal  organs  (visceral  gout). 

Diseases  of  the  Thyreoid  Gland 

Basedow's  disease  is  characterized  by  struma,  exophthal- 
mus,  tachycardia  (often  associated  with  dilatation  of  the 
left  ventricle  and  a  systolic  murmur),  tremor  of  the  fingers, 
and  nervous  irritability.     There  is  often  cachexia. 

Myxoedema  (cachexia  strumipriva)  is  characterized  by 
absence  of  the  thyreoid  gland,  a  swelling  of  the  skin  of 
the  entire  body,  gradual  failure  of  the  physical  and  psychi- 
cal powers,  loss  of  the  hair,  and  progressive  cachexia. 


CHAPTER   XI 

DIAGNOSIS   OF   THE   DISEASES   OF    THE   BLOOD 

As  far  as  the  history  is  concerned  an  inqiiir}^  into  the  hygienic 
conditions  of  the  patient,  his  habits,  and  his  occupation  is  of  value, 
because  psychical  excitement,  troubles,  and  worry  often  lead  to 
anseniia.  Ail  conditions  which  lead  to  chronic  loss  of  blood  may  be 
regarded  as  direct  causes  of  anaemia  :  ulcer  of  the  stomach  and  of 
the  intestine,  uterine  myomata,  profuse  menstruation,  certain  intes- 
tinal parasites  (the  Anchylostoinum  duodenale  and  Bothriocephalus 
latus)  ;  finally,  angemia  is  produced  by  all  those  severe  disturbances 
of  digestion  wliich  are  occasioned  by  atrophy  of  the  mucous  mem- 
brane of  the  stomach  and  of  the  intestines,  chronic  intestinal 
catarrh,  and  continued  attacks  of  diarrhoea.  Every  severe  injury 
to  the  organism,  as  well  as  every  disease  of  long  standing  (syphilis, 
for  example),  may  lead  to  true  anemia.  However,  many  blood 
diseases  develop  without  a  discoverable  etiological  cause ;  in  such 
cases  the  history  should  concern  itself  in  part  in  inquiring  care- 
full}^  about  the  indefinite  symptoms  which  usually  precede  the  full 
development  of  the  disordei',  such  as  malaise,  loss  of  energy,  dis- 
turbed sleep,  headache,  cardiac  palpitation,  dyspepsia  often,  etc. 

A  diagnosis  is  directed  to  a  disease  of  the  blood  when 
there  is  an  intense  ^xiUor  of  the  skin  and  the  mucous  mem- 
branes (see  p.  7),  associated  with  physical  weakness. 

As  has  been  already  mentioned  among  general  symptoms, 
a  blood  disease  may  be  secondary,  that  is,  caused  by  a  severe 
visceral  disease  which  leads  to  bodily  wasting,  such  as  tuber- 
culosis, carcinoma,  amyloid  degeneration,  etc.  Only  w^hen 
such  a  disease  can  be  excluded  may  a  diagnosis  of  a  specific 
disease  of  the  blood  be  considered ;  an  examination  of  the 
blood  will  then  substantiate  it. 

It  is  often  possible  to  diagnose  an  essential  (not  a  secondary) 
disease  of  the  blood  from  the  peculiar  color  of  the  skin.     The  skin 
R  241 


242  THE   DISEASES   OF   THE   BLOOD  chap. 

in  pernicious  ansemia  is  waxy  yellow,  often  having  a  greenish 
tinge  ;  this  color  is  wholly  characteristic. 

The  examination  of  the  blood  should  concern  itself  with  — 

1.  The  macroscopic  appearance  of  the  blood. 

2.  The  ordinary  microscopic  examination. 

3.  The  counting  of  the  corpuscles. 

4.  The  measuring  of  the  corpuscles.  , 

5.  The  preparation  of  stained  blood  specimens. 

6.  The  determination  of  the  amount  of  hsemoglobin. 

The  scientific  analysis  of  blood  diseases  includes  in  addition, 
among  other  things,  the  reaction,  the  amount  of  carbonic  acid  it 
contains,  and  the  investigation  of  its  metaholism  (see  previous  chap- 
ter). A  spectroscopic  examination  is  necessary  for  diagnostic  pur- 
poses in  many  cases  of  poisoning. 

For  the  purposes  of  examination  blood  should  be  obtained  by 
pricking  the  finger  tip  or  the  lobe  of  the  ear,  which  has  been  pre- 
viously washed  and  dried.  The  prick  should  be  made  with  a 
sharp  needle  or,  better,  with  a  vaccination  lancet ;  it  should  be 
deep  enough  that  the  blood  will  exude  of  its  own  accord ;  pressure 
must  not  be  used  ;  the  first  drop  is  wiped  away,  the  second  alone  is 
to  be  examined. 

1.    The  Macroscopic  Examination  of  the  Blood 

includes  the  color,  which  normally  should  be  of  a  bright  red,  and 
which  in  disease  becomes  paler  and  approaches  a  white.  The  rapid- 
ity with  which  it  coagulates  is  also  to  be  observed.  If  we  accustom 
ourselves  to  prick  as  uniformly  as  possible,  then  the  abundant  or 
scanty  amount  exuding  from  the  prick  will  furnish  some  conclu- 
sion as  to  the  amount  of  blood.  This  can  hardly  be  considered, 
though,  in  a  differential  diagnosis. 

2.    The  Examination  of  the  Fresh  Blood  Drop  under  the 

Microscope 

A  drop  of  blood  is  put  on  a  slide,  the  cover  glass  carefully  added  ; 
it  is  best  to  avoid  evaporation  and  consequent  drying  by  covering 
the  edges  of  the  cover  glass  with  some  warm  paraffine.  In  the 
examination  the  following  features  should  be  observed :  — 


XI 


THE    DISEASES   OF   THE   BLOOD 


243 


a.  Tlie  shape  of  the  red  blood  coipuscles;  normally  they 
have  the  shape  of  a  disc  with  a  central  depression.  The 
shape  is  unchanged  in  chlorosis  and  anaemia.  In  all  severe 
anaemias  changed  forms  appear,  such  as :  polkllocytes  (Fig.  40), 
which  are  club-shaped,  pear-shaped,  biscuit-shaped,  or  kidney- 
shaped  red  blood  corpuscles  ;  microcytes,  red  blood  corpuscles 
much  smaller  than  the  ordinary  red  corpuscle ;  and  macro- 
cytes,  which  are  decidedly  larger  than  these. 


Nucleated  red  blood -cells. 


Poikilocytes. 


Leucocytes.        Red  blood-cells. 
-Fig.  40.  —  The  Blood  in  Pernicious  Anemia. 

b.  The  tendency  to  the  rouleaux  formation ;  this  tendency 
is  absent  in  all  conditions  of  extensive  diminution  in  the 
number  of  red  corpuscles,  therefore  in  all  severe  anaemias. 

c.  Tlie  number  of  the  red  blood  corpuscles ;  although  this 
can  only  be  positively  determined  by  a  counting  apparatus, 
yet  after  practice  in  preparing  specimens  uniformly  we  can 
reach  the  position  to  tell  Avhether  the  number  is  essentially 
diuiinished  by  the  ordinary  microscopic  a^jpearance.  The 
increase  of  erythrocytes  is  the  sign  of  anaemia. 


244  THE   DISEASES   OF  THE    BLOOD  chap. 

d.  The  color  of  the  red  blood  corpuscles,  normally  yellowish- 
red,  is  more  or  less  pale  in  many  diseases,  especially  in 
chlorosis. 

e.  The  nuniber  of  the  ivhite  blood  corpuscles  and  their  rela- 
tion to  the  red.  Normally,  1  white  exists  to  every  300  red 
blood  corpuscles,  or,  in  other  words,  in  a  microscopic  field 
with  open  diaphragm  and  a  high  objective  (Leitz  7),  3  to  5 
white  corpuscles  will  be  present. 

The  abundant  presence  of  leucocytes  in  a  visual  field  (over 
10)  is  an  important  sign  of  disease.  ^Moderate  increase  of 
the  leucocytes  (1  white  to  100  red)  is  called  a  hyperleucocyto- 
sis  (see  below).  Very  great  increase  of  the  leucocytes  is  the 
sign  of  leiiccemia  (1  to  50  and  up  to  1  to  2).  These  results 
should  be  controlled  by  the  counting  apparatus. 

With  practice  with  the  ordinary  microscopical  examination  we 
may  be  able  to  recognize,  for  instance,  the  nucleated  red  blood 
corpuscles  as  well  as  the  variations  in  the  white  corpuscles.  Yet 
these  featm-es  are  more  easily  recognized  in  examining  stained 
preparations. 

3.    Counting  the  Blood  Corpuscles 

To  count,  the  Thoma-Zeiss  counting  apparatus  is  used.  It  con- 
sists of  a  glass  capillary  tube  that  is  blown  out  near  the  upper 
extremity  into  a  bulb,  which  serves  to  draw  up  and  to  dilute  the 
blood,  and  of  a  counting  chamber.  The  blood  is  drawn  up  into 
the  gi'aduated  tube  to  the  mark  0.5  (or  to  1),  the  point  of  the  tube  is 
carefully  wiped,  and  then  some  of  a  3  per  cent,  solution  of  sodium 
chloride  (salt)  is  drawn  into  the  tube  until  the  whole  contents  of 
the  tube  reach  the  mark  101.  The  fluid  in  the  tube  is  then 
thoroughly  mixed  by  shaking  (this  is  facilitated  by  the  little  glass 
ball  which  is  found  in  the  bulb).  After  this  the  mixture  is  placed 
in  the  counting  chamber,  which  is  exactly  0.1  mm.  deep  and  the 
bottom  of  which  is  divided  into  microscopical  squares.  The  space 
over  each  square  is  exactly  ^^5^00  ^.c.  When  placing  the  cover  glass 
over  the  counting  chamber,  care  should  be  taken  to  prevent  the 
formation  of  air-bubbles.  A  large  number  of  these  squares  should 
be  counted,  every  10  of  which  are  marked  oft'  by  darker  lines,  and 
in  this  way  we  obtain  the  average   number   of   blood   corpuscles 


XI  THE    DISEASES    DF    THE    BLOOD  245 

lying  in  each  square.  Tliis  average  is  then  miilfciplied  by  800,000 
(if  ilie  l)l()0(l  was  sucked  up  to  tlie  niai-k  1,  it  is  only  inii]li}»lied 
by  400,000),  for  the  reason  that  tlie  blood  was  diluted  100  times 
and  the  space  over  each  square  is  ^^^^  c.c. ;  the  result  will  give  the 
numlxM-oF  red  blood  corpuscles  in  every  cubic  milliinetre  of  blood. 
The  counting  of  the  white  corpuscles  is  performed  in  exactly  the 
same  way,  although  the  blood  is  diluted  in  a  separate  pipette  only 
10  times.  It  is  of  advantage  to  add  some  methyl-violet  to  the  dilut- 
ing fluid,  for  the  leucocytes  take  lip  this  stain  and  appear  much 
more  prominently  than  otherwise.  The  destruction  of  the  red 
blood  corpuscles  (by  diluting  the  blood  with  1  per  cent,  of  acetic 
acid)  is  recommended  in  counting  the  white  corpuscles. 

In  healthy  men  the  inimber  of  the  red  blood  corpuscles 
is  5,000,000,  in  women  between  4,000,000  and  5,000,000,  in 
every  cubic  millimetre.  In  chlorosis  the  number  is  not  at 
all  or  but  little  changed,  but  in  all  anaemias  it  is  much  di- 
minished, even  down  to  500,000;  in  severe  leucaemia  there 
is  also  a  diminution  of  the  number  of  red  blood  corpuscles. 

The  number  of  white  blood  corpuscles  in  health  is  5000 
to  8000  in  every  cubic  millimetre.  An  increase  in  the  num- 
ber (liyperleucocytosis)  occurs  physiologically  during  the 
digestion  of  the  albuminoids  (10,000  to  20,000)  and  occurs 
j)athologically  in  many  infectious  and  cachectic  diseases,  e.g., 
}meumonia  and  carcinoma  (see  p.  250).  Only  an  increase  to 
over  50,000  in  a  cubic  millimetre  would  justify  a  diagnosis 
of  leucmmia;  this  diagnosis  will  be  probable  if  with  an  ex- 
isting hyperleucocytosis  the  number  of  leucocytes  increases 
in  a  short  time. 

4.    Measuring  the  Blood  Corpuscles 

The  size  of  the  red  blood  cor[)uscles  may  be  well  estimated  and 
macrocytes  and  microcytes  recognized  with  sufficient  distinctness. 
For  a  careful  examination  a  micrometer  eyepiece  should  be  used. 
The  red  blood  corpuscles  of  the  healthy  vary  in  size  from  G.5  to 
9.4^  (microns),  on  the  average  they  are  7.6 /x;  they  are  of  equal 
size  in  the  same  individual.  Macrocytes  are  those  whose  size  is  10 
to  12 /x,  gigantocytes  12  to  15/x,.  Their  presence  denotes  a  grave 
anöemia.     The  size  of  the  leucocytes  varies  extremely. 


246  THE   DISEASES   OF   THE  BLOOD  chap. 


5.    The  Preparation  and  Microscopical  Appearance  of    Stained 

Specimens 

(According  to  Ehrlich) 

The  drop  of  blood  is  taken  up  from  the  finger  tip  dii'ectly  on 
to  the  cleansed  cover  glass,  which  is  placed  lightly  on  another 
clean  cover  glass  in  such  a  manner  that  the  edges  do  not  coincide 
and  then  the  glasses  are  drawn  apart  without  exerting  pressure, 
which  must  be  avoided.  Care  should  be  taken  that  the  fingers  do 
not  touch  the  cover  glasses,  because  the  warmth  and  moisture  of 
the  skin  will  change  the  very  sensitive  blood  corpuscles.  The  blood 
has  now  been  finely  spread  in  a  thin  layer  on  both  cover  glasses. 
The  spreads  are  now  dried  by  the  air  and  thereafter  fixed  by  heat. 
The  heating  must  be  gradual,  for  which  purpose  the  cover  glasses 
are  placed  in  a  hot-air  oven  or  on  a  copper  plate ;  the  latter  is 
heated  at  one  end  to  120^  C.  and  kept  at  this  temperature  for 
2  hours.     After  they  have  cooled  they  are  ready  for  staining. 

The  dj^e  most  frequently  used  is  the  eosin-haematoxylin  solution 
(haematoxylin,  2;  alcohol-,  glycerine,  and  distilled  water,  ää  100 ; 
glacial  acetic  acid,  10,  to  which  alum  in  excess  is  added ;  the 
solution  should  stand  several  weeks,  then  a  small  quantity  of 
eosin  is  added  to  it).  The  spreads  are  put  in  this  solution  and 
kept  there  for  30  minutes,  when  they  are  removed  and  washed 
with  water ;  the  red  blood  corpuscles  will  appear  red,  the  nuclei 
of  the  white  and  those  of  the  red  are  deeply  stained  bluish-black, 
and  the  eosinophile  granulations  (see  below),  red;  the  proto- 
plasm of  the  white  blood  cells  is  almost  unstained,  having  only  a 
pale-red  tint. 

Ehrliches  three-color  mixture  (see  p.  lü)  is  very  serviceable  for 
staining  the  blood.  This  stains  the  nuclei  a  greenish-blue,  the 
eosinophile  granulations  red,  the  red  blood  cells  orange. 

Beautiful  results  are  obtained  with  the  eosin-nigrosin-auran- 
tia-glycerine  mixture.  (To  1  volume  of  glycerine  saturated  with 
aurantia,  add  1  to  2  volumes  of  glycerine ;  shake  the  mixture 
thoroughly  and  then  add  eosin  and  nigrosin  in  excess ;  satu- 
ration results  after  long-continued  shaking.)  The  haemoglobin 
takes  up  the  yellowish-red  tint  of  the  aurantia,  all  nuclei  are  gray 
or  black,  and  the  eosinophile  granules  are  red. 

The  stained  preparations  are  best  examined  with  an  oil  immer- 
sion lens  and  with  o]teii  diaphragm. 


XI 


THE   DISEASES   OF  THE   BLOOD 


247 


111  a  stained  specimen  we  recognize :  — 

1.  The  nucleated  red  blood  corpuscles ;  these  are  always 
a  sign  of  severe  blood  disease ;  they  are  present  in  many 
anaimias,  and  occur  less  seldom  in  leucaemia;  nucleated 
megalocytes  and  gigaiitocytes  indicate  very  grave  anaemia. 
Still  in  spite  of  their  presence,  improvement,  even  a  cure, 
may  result. 

MonoiHicli'iir  ci' 


Lymphocytes. 


Red  blood-cells. 


J  Eosinophile 
■^      cells. 


Polynuclear 
cells. 


Fig.  41.  —  Schematic  Eepresentation  of  Various  Kinds  of  Leucocytes. 

2.  The  different  forms  of  the  naliite  blood  corpuscles  :  — 

a.  Lympliocytes,  of  varying  size ;  usually  somewhat 

larger  than  a  red  blood  corpuscle,  possessing  a 
round  nucleus  and  small  protoplasmic  bod}^;  they 
arise  from  the  lymphatic  glands,  and  a  marked 
increase  of  them  indicates  lymphatic  leuccEmia. 

b.  Mononuclear  leucocytes  are  much  larger  than  the 

red  corpuscles,  and  have  a  large  ovoid  nucleus 
and  a  large  protoplasmic  body;  from  them  are 
developed  the 

c.  Polynuclear  leucocytes,  which  have  a  polymorphous 

nucleus,  and  form  the  mass  of  the  leucocytes ; 


248  THE   DISEASES   OF   THE   BLOOD  chap. 

they  are  chiefly  present  in  pus.  Mono-  and 
polynuclear  cells  are  increased  in  splenic  and 
in  myelogenic  leiicmmia. 
d.  Eosinopliile  cells,  large,  round,  and  nucleated; 
they  are  characterized  by  the  glistening  gran- 
ules in  the  protoplasmic  body  of  the  cell ;  these 
granules  are  deeply  stained  by  eosin.  These 
cells  arise  in  the  bone-marrow,  are  seldom 
found  in  normal  blood,  and  when  abundantly 
present  justify  the  conclusion  that  there  is  an 
implication  of  the  marrow  of  the  bone. 

6.    The  Determination  of  the  Amount  of  Haemoglobin  in  the 

Blood 

The  amount  of  ha?moglobin  in  the  blood  is  determined  with 
sufficient  accuracy  by  means  of  Fleischl's  hcemometer.  The  color 
of  the  blood  diluted  with  water  is  compared  with  a  wedge  of  glass 
which  is  colored  purpUsh-red.  The  blood  is  sucked  up  in  a  capil- 
lary tube  of  known  dimensions,  dissolved  in  water  in  the  one  com- 
partment of  a  glass  box  which  is  partitioned  into  two  divisions ; 
under  the  other  compartment,  which  is  filled  with  water  alone,  the 
colored  glass  wedge,  whose  color  increases  in  intensity  as  the  wedge 
increases  in  depth,  moves  across.  The  wedge  is  2:>rovided  with  a 
scale,  empirically  determined  in  such  a  manner  that  the  100  mark 
of  its  color  corresponds  to  the  normal  haemoglobin  in  the  blood. 
Under  the  glass  bottom  of  the  box  a  light  is  reflected  by  a  gypsum 
plate ;  should  then  the  color  be  alike  in  both  compartments,  the 
number  indicated  on  the  scale  at  this  stage  will  denote  the 
haemoglobin  contents  of  the  blood.  The  limits  of  error  in  this 
instrument  are  within  15  per  cent.  Gower's  hfenioglobinometer 
determines  the  amount  of  the  coloring  matter  of  the  blood  by 
comparing  a  specimen  of  diluted  blood  with  some  artificially 
colored  glass  rods.  Pretty  accurate  results  are  obtained  by 
the  expert  who  uses  photometric  spectral  analysis  suggested  by 
Vierordt;  but  its  use  is  extremely  difficult. 

The  amount  of  haemoglobin  in  the  blood  is  much  dimin- 
ished in  chlorosis,  while  the  number  of  red  corpuscles  is 


XI  THE    DISEASES   OF   THE   BLOOD  249 

not  at  all  affected.  In  the  other  ansemias  a  diminution  in 
the  amount  of  haemoglobin  will  coincide  with  a  decrease  in 
the  number  of  red  blood  corpuscles. 

The  absolute  amount  of  hsemogiobiii  is  13  to  15  g.  to  every 
100  c.c.  of  blood,  in  women  usually  a  little  less  than  in  men. — 
Haemoglobin  is  converted  into  albumin  and  hcematin.  Hsematin 
with  hydrochloric  acid  produces  hcemin,  which  form  in  beautiful 
crystals  (Teichmann's),  by  whose  presence  the  slightest  trace  of 
blood  may  be  recognized. 

Teichmann's  blood  test.  —  A  small  quantity  of  dried  blood,  to 
which  1  to  2  drops  of  glacial  acetic  acid  and  a  small  crystal  of 
common  salt  are  added,  is  heated  in  a  glass  dish  over  a  full  flame 
until  it  boils ;  it  is  then  permitted  slowly  to  evaporate,  when 
numerous  brownish-yellow  needles  and  crystals  of  htemin  will  be 
formed. 

The  reaction  of  the  blood  is  alkaline  ;  the  alkalinity  is 
diminished  in  severe  anaemias,  in  fever,  in  severe  diabetes, 
and  in  the  emaciation  stage  of  carcinoma. 

The  reaction  of  the  blood  may  not  be  determined  simply  with 
litmus,  etc.,  on  account  of  the  individual  color  of  the  blood  and 
chiefly  because  the  blood  contains  different  acids  and  bases  in 
varying  degrees  of  saturation.  In  one  sense  the  alkalinity  of  the 
blood  may  be  reckoned  from  the  amount  of  carhonic  acid  the  blood 
contains,  for  there  is  an  approximately  standard  relation  between 
the  alkalescence  and  the  amount  of  COo. 

The  determination  of  the  specific  gravity  has  thus  far  been  of 
little  use  for  practical  diagnostic  purposes ;  in  health  it  varies 
between  1015  and  1075. 

The  spectroscopic  examination  of  the  blood  is  of  impor- 
tance in  diagnosing  carbonic  oxide  intoxication. 

Normal  blood  strougly  diluted  with  water  will  show  the  absorp- 
tion bands  of  oxykcemoglohin  in  the  yellow  and  green  (between 
the  Frauenhofer  lines  of  D  and  E).  On  adding  a  few  drops  of  a 
solution  of  ammonium  sulphide,  the  two  lines  will  A^anish  and  a 
single  line  (between  D  and  E)  of  reduced  hsemoglobin  will  apj)ear. 

The  t/right  red  blood  of  carbonic  oxide  intoxication  shows  likewise, 
when  viewed   in  the  spectroscope,  two  lines  between  D  and  E, 


250  THE   DISEASES   OF   THE   BLOOD  chap. 

though  these  appear  closer  to  each  other  than  the  oxyhsemoglobin 
lines.  On  the  addition  of  ammonium  sulphide  the  lines  of  the 
CO  h?emogiobin  do  not  disappear. 

In  cases  of  poisoning  with  potassium  chlorate,  anilin,  antifebrin, 
phenacetin,  etc.,  the  color  of  the  blood  is  like  chocolate,  and  in 
the  spectroscope,  in  addition  to  the  two  oxyhsemogiobin  lines, 
an  absorption  line  is  observed  in  the  red  which  belongs  to  methce- 
moqlohin.  On  adding  some  ammonium  sulphide,  all  three  lines 
disappear  and  the  one  line  of  reduced  haemoglobin  puts  in  an 
appearance. 

Chief  Symptoms  of  the  Most  Importaxt  Diseases  of 

THE  Blood 

Chlorosis  occurs  in  young  persons,  especially  in  young 
girls;  still  sometimes  it  occurs  in  women,  especially  after 
parturition.  It  is  characterized  by  pallor  of  the  skin, 
intense  fatigue,  often  by  dyspepsia,  palpitation,  etc.  The 
essential  changes  in  the  blood  are  a  great  diminution  in 
the  amount  of  hcemoglobin  Avithout  an  essential  decrease  in 
the  number  of  red  or  an  increase  in  the  number  of  white 
blood  cells.     The  prognosis  is  usually  good. 

Hyperleucocytosis  is  a  temporary  increase  in  the  number 
of  white  blood  corpuscles ;  it  is  a  symptom  of  many  inflam- 
matory diseases  (occurs  principally  in  pneumonia,  erysipelas, 
meningitis,  and  in  the  cachectic  diseases,  especially  in  car- 
cinoma). In  typhoid  fever,  malaria,  glanders,  and  in  many- 
forms  of  sepsis  hyperleucocytosis  is  absent.  It  occurs 
physiologically  during  digestion.  Hyperleucocytosis  may 
extend  to  an  increase  to  100,000  leucocytes  in  one  cubic 
millimetre  of  blood.  The  characteristic  differential  point 
between  it  and  leuccpmia  lies  in  the  demonstration  of  the 
original  disease  and  in  the  increase  of  the  pol^^nuclear 
leucocytes  alone.  The  prognosis  is  dependent  on  the  origi- 
nal disease  producing  it. 

Leucaemia  is  characterized  by  a  great  increase  in  the  num- 
ber of  white  blood  corpuscles,  so  that  the  relation  may  be 


XI  THE   DISEASES   OF   THE   BLOOD  251 

from  1  to  60,  to  1  to  2.  It  is  to  be  differentiated  from  the 
primary  stage  of  a  leucocytosis  in  the  more  rapid  increase 
of  the  leucocytes  in  leucaemia.  The  red  cells  are  usually 
diminished  in  number,  are  often  nucleated,  and  the  amount 
of  haemoglobin  is  also  diminished.  The  following  forms 
exist,  although  each  may  merge  into  the  others. 

1.  Lymphatic  leucaemia.  Swelling  of  all  the  lymph 
glands ;  the  lymphocytes  of  the  blood  are  increased. 

There  is  a  well-characterized  form  of  acute  leucaemia  in  which 
only  the  Ivmpliocytes  are  increased.  It  runs  a  rapidly  fatal  course, 
accompanied  by  the  clinical  phenomena  of  hsemorrhagic  diathesis, 
dyspnoea,  enlargement  of  the  lymph  glands  and  spleen  ;  in  many 
organs  leucfemic  hyperplasia  appears.  The  uric  acid  excretion  is 
enormously  increased. 

2.  Myelogenic  leuccemia.  There  are  many  eosinophile  as 
well  as  mononuclear  leucocytes  and  nucleated  red  blood 
corpuscles. 

3.  Sj>lenic  leucaemia.  The  spleen  is  very  large.  The 
blood  contains  many  eosinophile  and  mononuclear  cells.  A 
progressive  cachexia  characterizes  all  three  forms,  which 
terminate  fatally. 

Pseudo-leucaemia  is  the  name  given  to  the  disease  which 
has  the  clinical  features  of  leucaemia,  such  as  cachexia, 
lymphatic  gland  enlargements,  and  a  splenic  enlargement, 
but  which  runs  its  course  irithout  the  changes  in  the  blood 
characteristic  of  true  leuccemia.  The  number  of  leucocytes 
is  normal  and  there  is  little  diminution  of  the  red  cells 
and  of  haemoglobin. 

Pseudo-IeuccEima,  presenting  large  swellings  of  the  lymph  glands, 
is  called  Hodglin's  disease. 

Pernicious  anaemia.  The  number  of  red  blood  cells  is 
much  diminished,  even  to  400,000  in  each  cubic  millimeter. 
Poikilocytes,  macrocytes,  and  microcytes  are  in  abundance. 
There  are  nucleated  red  corpuscles  and  nucleated  gigantn- 


252  THE   DISEASES   OF   THE   BLOOD  chap,  xi 

cytes.  The  amount  of  liaemogiobin  is  relatively  iiieieased, 
while  the  number  of  leucocytes  is  normal  or  even  dimin- 
ished.    The  prognosis  is  most  grave. 

Secondary  anaemia  occurs  in  the  course  of  severe  dyspep- 
sia, anchylostomiasis,  carcinoma,  phthisis,  tertiary  syphilis, 
malaria,  amyloid  degeneration,  chronic  intoxications,  etc. 
There  is  a  large  decrease  of  the  red  blood  cells;  macro- 
cytes  and  microcytes  are  present,  but  rarely  are  there  any 
nucleated  red  cells ;  the  amount  of  haemoglobin  is  also 
diminished.  The  number  of  polynuclear  leucocytes  is  in- 
creased. The  prognosis  of  secondary  ansemia  depends  on 
its  causative  disease ;  should  we  be  successful  in  removing 
that,  the  anaemia  may  be  cured.  Secondary  anaemia  may  go 
into  pernicious  anaemia;  on  this  account  in  some  cases  a 
differential  diagnosis  may  be  extremely  difficult. 


CHAPTER   XII 

ANIMAL  AND   VEGETABLE   PARASITES 
I.   Animal    Parasites 

The  animal  parasites  which  are  found  in  or  upon  the 
human  body  are,  in  j^art,  harmless  organisms  which  infest 
the  skin  or  the  intestines  and  are  without  diagnostic  signifi- 
cance ;  in  part,  however,  they  are  productive  of  diseases, 
more  or  less  severe,  the  treatment  of  which  is  dependent 
almost  wholly  upon  a  correct  diagnosis. 

In  the  following  summary,  the  principal  animal  parasites 
are  included :  — 

I.   Protozoa. 

a.  Rhizopods  :  Monads  and  Amoeba  coll. 

b.  Sporozoa :  Coccidia. 

c.  Infusoria :  Cercomoiias  intestinalis,  Trichomonas  intes- 

tinalis, Paramecium  coli. 
II.   Vermes  (Worms). 

a.    Tape-worms  {Cestodia). 

1.  Taenia  solium. 

2.  Taenia  mediocanellata  or  sasfinta. 

3.  Bothriocephalus  latus. 

4.  Taenia  nana. 

5.  Taenia  flavopunctata. 

6.  Taenia  cucumerina. 

7.  Taenia  echinococcus. 
h.    Flukes  (Trematod(i). 

1.  Distoma  hepaticum. 

2.  Distoma  lanceolatum. 

3.  Distoma  haenuitohium. 

c.    Thread  icorms  or  Round  worms  (^Netnatoidea). 
1.    Ascaris  lumbricoides. 
253 


254  ANIMAL   AND   VEGETABLE   PARASITES  chap. 


2. 

Ascaris  inystax. 

3. 
4. 
5. 

6. 
7. 

Oxyuris  vermicularis. 
Auchylostoraa  duodenale. 
Tricocephalus  dispar. 
Trichina  spiralis. 
Anguillula  intestinalis. 

8. 

Filaria  sanguinis. 

.   Arthrozoa. 

1. 
2. 
3. 

Acarus  scabiei. 
Acarus  folliculorum. 
Pediculi. 

4. 

Pulex  irritans. 

The  Protozoa  are  practically  without  diagnostic  significance. 
They  are  round,  granular  organisms,  about  1  /jl  in  length,  some  of 
the  infusoria  being  a  little  larger,  provided  with  ciliar  or  flagellse. 
They  are  found  in  healthy  faeces,  in  the  discharges  of  chronic  diar- 
rhoea, and  sometimes  in  the  normal  vaginal  secretions.  Only  the 
aniceba  coli  is  the  causative  factor  of  dysentery,  and  has  therefore 
diagnostic  significance. 

Tape-worms 

The  tape-worms  are  principally  intestinal  parasites.  As 
such  they  evoke  a  complex  of  dyspeptic,  dysenteric,  and 
nervous  symptoms  which  are,  in  a  measure,  exceedingly 
painful  and  which  disappear  upon  the  expulsion  of  the 
parasite.  The  diagnosis  of  the  presence  of  a  tape-worm  can 
be  established  only  by  the  passage  of  segments  (proglot- 
tides) of  the  worm. 

Tape-worms  consist  of  a  head  (scolex)  smd  joints  (proglottides). 
They  reproduce  by  sexual  alternation.  The  bisexual  segments 
bud  from  the  head,  the  impregnated  eggs  entering  the  stomach  of 
some  second  animal,  the  intermediate  host.  Here  the  coverings  of 
the  eggs  are  digested  and  the  embryo  becomes  free.  It  reaches  the 
tissues  of  the  intermediate  host  in  the  form  of  a  Cysticercus.  If  the 
Cysticercus  reaches  the  stomach  of  man  with  his  food,  a  new  tape- 
worm is  developed. 

Taenia  solium  (intermediate  host,  the  pig)  attains  a  size  of  from 
2  to  3  M.,  its  proglottides  are  from  9  to  10  mm.  long  and  from  6  to 
7  mm.  broad.      The  proglottides  nearest  the  head  are  short  and 


XII 


ANIMAL   AND   VEGETABLE   PARASITES 


255 


gi-adually  increase  in  size  as  the  tail  is  approached.  The  head  has 
the  size  of  a  pin.  Lender  the  microscope  may  be  seen  four  sucking 
discs,  usually  pigmented,  and  a  proboscis  or  rostellum  with  from 
25  to  30  hooklets  of  different  sizes  (Fig.  42).  The  segments  have 
lateral  sexual  openings 
and  a  uterus  with  few 
branches.  The  eggs 
are  oval,  about  0.036 
mm.  long  and  0.03  mm. 
broad,  with  a  thick 
covering  and  radial 
striae.  In  the  interior 
of  the  ovule,  the  hook- 
lets  of  the  embryo  are 
visible.  The  larvse 
(^Cysticercus  cellulosce^ 
are  the  size  of  a  pea 
and  may  be  deposited 
in  the  organs  of  the 
body  (mainly  the  skin, 
the  muscles,  the  brain, 
the  eye)  by  auto-infec- 
tion,  II  they  have  en-  ^ig.  42.  —  Micboscopic  Pictuee  of  Tjtn-ia  solitm 
tered  the  stomach.  (Head,  Peoglottides,  Egg). 


Tcenia  solium  is  the  tape-worm  most  frequently  found  in 
the  intestine.  It  is  usually  possible  to  distinguish  this 
species  with  the  naked  eye  or  with  a  magnifying  glass,  by 
the  delicacy  and  transparency  of  its  segments  and  by  the 
few  ramifications  (7  to  12)  of  its  uterus. 

The  diagnosis  of  Cysticercus  cellulosce  of  the  skin  is  usually  easy  to 
make.  Multiple  movable  tumors,  from  the  size  of  a  pea  to  that  of 
a  bean,  are  observed.  Excision  and  examination  makes  the  cer- 
tainty of  diagnosis  more  positive.  The  presence  of  a  Cysticercus  in 
the  eye  may  be  demonstrated  ophthalmoscopically.  The  diagnosis 
of  Cysticercus  in  the  brain  is  made  probable,  if  focal  cerebral  symp- 
toms appear  without  demonstrable  etiology,  and  if.  at  the  same 
time,  cysticerci  are  present  in  the  skin  or  in  the  eye. 

Taenia  saginata  or  mediocanellata  (intermediate  host,  cattle)  are 
from  4  to  5  M.  long.     The  head  has  no  rostellum  or  circle  of  hook- 


256 


ANIMAL   AND   VEGETABLE   PARASITES 


CHAP. 


lets,  but  is  provided  with  four  very  powerful  sucking  discs  (Fig.  43). 
The  proglottides  are  longer  than  those  of  Tcenia  solium  and  do  not 
taper  as  they  approach  the  head.    The  generative  cloaca  is  situated 

at  the  sides  and  the  uterus 
has  many  ramifications. 
The  eggs  are  somewhat 
more  oval  than  those  of 
Tcenia  solium,  but  other- 
wise the  resemblance  is 
marked,  although  the 
booklets  of  the  embryo 
are  not  visible.  The  larvae 
does  not  develop  in  the  tis- 
sues of  the  human  body. 

The  segments  of  a 
Tcenia  mediocanellata 
may  be  recognized  with 
the  naked  eye ;  they  are 
thicker  and  not  so  deli- 
cate as  those  of  Tcenia 

solium  and  the  uterus  has  many  more  ramifications  (from 

15  to  20). 

Bothriocephalus  latus  (intermediate  host,  various  fishes,  pike, 
salmon,  etc. ;  geographical  distri- 
bution limited  mainly  to  the  coast 
of  the  Baltic  and  Switzerland)  is 
from  4  to  15  M.  long.  Its  head  is 
2  mm.  long,  1  mm.  broad,  club- 
shaped,  and  is  provided  in  the 
median  line  with  grooves  which 
act  as  sucking  discs  (Fig.  44).  The 
segments  nearest  the  head  are  short 
and  narrow,  those  further  away 
almost  quadrilateial.  The  uterus, 
when  filled  with  eggs,  is  brown  in 
color  and  presents  a  star-shaped 
form.     The   ovules   are  oval,  0.07 

mm.  long,  0.04.">  mm.  broad,  have  a  brownish  shell,  and  are  pro- 
vided with  a  little  cover. 


Fig.  43.  —  Microscopic  Picture  of  T^.nia  sag- 
iNATA  (Head,  Proglottides,  Egg). 


Fig.  44.  —  Microscopic  Picture  of 
Bothriocephalus  latus  (Head, 
Prog  lottides,  Egg). 


XII  ANIMAL   AND   VEGETABLE    PARASITES  257 

The  diagnosis  of  Bothrioceplialus  latus  is  of  importance, 
since  its  presence  may  evoke  a  jirofound  ancemia,  which  dis- 
appears upon  the  expulsion  of  the  tape-worm.  The  proglot- 
tides of  bothriocephalus  may  be  recognized  by  their  brown 
color  and  by  the  rosette-shaped  uterus. 

Tcenia  nana  is  from  10  to  15  mm.  long,  0.5  mm.  broad.  The 
diameter  of  the  head,  which  has  a  rostelhim  and  sucking  discs,  is 
0.3  mm.  The  segments  are  short,  4  times  as  broad  as  they  are 
long.  The  uterus  is  oblong  in  shape.  The  ovules  measure  from 
0.03  to  0.04mm.  in  diameter;  they  are  surrounded  by  a  double 
membrane  without  a  striated  shell.  In  the  interior  of  the  egg,  the 
embryo  with  its  booklets  is  visible.  From  4000  to  5000  of  these 
tape-worms  may  infest  the  intestines  simultaneously.  T?enia  nana 
has  been  seen  only  in  southern  countries  (Italy,  Egypt),  and  is  said 
to  call  forth  severe  psychical  and  nervous  disturbances. 

Taenia  flavopunctata  and  Taenia  cucumerina  are  extraordinarily 
rare. 

Taenia  echinococcus  is  found  in  the  human  body  only  in 
its  larval  stage. 

The  tape-worm  itself  exists  only  in  the  intestines  of  dogs.  It 
is  4  mm.  long.  The  head  possesses  a  circle  of  from  20  to  30  hook- 
lets.  The  embryo  reaches  the  human  stomach  and  intestine  and 
becomes  encysted.  The  cyst-wall  consists  of  two  layers,  an  outer, 
finely  lamellated  layer,  the  cuticula,  formed  of  chitinous  material, 
and  an  inner  layer,  the  parenchymatous,  which  contains  muscle 
fibres  and  blood-vessels.  The  scolex  or  head  develops  in  the  paren- 
chymatous layer  and  is  provided  with  booklets  and  sucking  discs. 
The  echinococcus  cyst  may  be  unilocular  or  secondary  or  daughter 
cysts  may  develop  within  it,  or  it  may  consist  of  a  mass  of  small 
cavities,  filled  with  a  colloid  fluid,  the  walls  of  which  may  show 
concentrically  arranged  layers.  This  is  known  as  a  multilocular 
echinococcus  cyst. 

JEchinococcus  cysts  have  their  principal  seat  in  the  liver, 
but  are  found,  less  often,  in  the  lungs,  the  brain,  or  the 
heart. 

The  symptoms  evoked  are  those  of  a  large  cyst  the  nature 
of  which  is  determined  by  aspiration  and  microscopic  exam- 


258 


ANIMAL   AND   VEGETABLE    PARASITES 


CHAP. 


illation  of  the  aspirated  material.  Sometimes,  characteristic 
membrane  and  hooks  (Fig.  45)  are  seen,  or  chemical  examina- 
tion of  the  fluid  discloses  some  of  its  peculiar  properties. 

The  fluid  of  an  echinococcus  cyst  is  usually  clear,  of  a  specific 
gravity  of  from  1008  to  1013.  It  contains  little  or  no  albumin,  but 
sodium  chloride  is  present  in  large  quantities,  and  frequently  grape- 
sugar  and  succinic  acid  are  found. 

The  presence  of  succinic  acid  may 
be  determined  as  follows :  the  fluid  is 
heated  over  a  water  bath,  is  made  acid 
by  the  addition  of  hydrochloric  acid, 
and  is  then  shaken  up  with  ether.  The 
ether  is  evaporated  and  if  succinic  acid 
is  present,  a  crystalline  jelly  remains, 
which  is  to  be  dissolved  in  water. 
With  ferric  chloride,  succinic  acid 
gives  a  rust-colored,  colloid  precipitate 
which  on  heating  in  a  test-tube  gives 
Fig.  45. -Echinococcus  Mem-  o«  a  vapor  exceedingly  irritating  to 
BRAKE  AND  HooKLETs.  the  mucous  membraues. 


Flukes  (Trematoda) 

Distoma  hepaticum  is  of  a  leaf-like  form,  has  a  short,  globular 
head,  and  attains  a  length  of  28  mm.  The  ovules  are  oval, 
0.13  mm.  long,  0.08  mm.  broad,  and  are  provided 
with  a  cover  (Fig.  46).  This  parasite  is  rarely 
found  in  the  biliary  passages  in  man,  and  its  eggs 
have  been  occasionally  found  in  the  intestines.  Its 
diagnostic  importance  is  insignificant,  but  the  pos- 
sibility of  its  confusion  with  eggs  of  important 
diagnostic  worth  nuist  be  mentioned. 

Distoma  hcematohium  occurs  only  in  the  tropics. 
Its  residence  is  in  the  portal  system  of  veins  and 

in  the  veins  of  the  bladder  and  of  the  rectum.     It 
gJffM  causes  diarrhoea,  hsematuria,  and  ulcerations  of  the 

W',y  mucous  membranes. 

\|j|  The  male  worm  has  a  length  of  from   12   to 

Fig.  47.  24  mm.,  the  female  from  16  to  19  mm.     The  abdo- 

Ego  of  Distoma      "^611  of  the  male  has  a  sulcus  opening  downward,  in 

H^MATomuM.        which  the  female  is  carried.     The  eggs  (Fig.  47) 


Fig.  46. 

Egg  of  Distoma 

hepaticum. 


XII 


ANIMAL   AND   VEGETABLE   PARASITES 


259 


are  found  in  the  lungs,  the  liver,  and  the  bladder,  are  0.12  mm. 
long  and  0.04  mm.  broad,  and  are  provided  at  the  end  or  side  with 
a  thorn-like  projection. 

Distoma  lanceolatum  is  a  lancet-shaped  worm,  7  to  8  mm.  long. 
2  to  3.5  mm.  broad,  smaller  than  but  siinilar  to  Distoma  hepaticum. 
The  parasite  is  very  rarely  found  in  the  gall-bladder  or  gall-pas- 
sages, and  the  eggs  are  still  more  rarely  seen  in  the  faeces.  Its 
diagnostic  importance  is  slight. 


Thread  Worms  or  Round  Worms  (Nematoidea) 

Ascaris  lumbricoides  is  the  common  thread  worm.  The  male 
attains  a  length  of  25  cm.,  the  female  of  50  cm.  It  appears  in 
large  numbers  in  the  human  small  intestine.  In 
general  it  is  a  harmless  parasite,  but  sometimes 
reflex  convulsions  in  children  are  attributed  to  it. 
The  eggs  are  found  in  the  f^ces  in  large  numbers. 
They  are  round,  yellowish-brown,  of  a  diameter  of 
0.06  mm.  In  the  fresh  state,  they  are  surrounded 
by  a  crenated,  albuminous  covering  (Fig.  48), 
which  in  turn  surrounds  a  thick,  concentric,  striped 
sheU  which  contains  a  granular  material. 

Oxyuris  vermicularis,  thread  worm  or  pin  worm. 

The  male  is  4  mm.,  the  female  10  mm.  in  length. 
The  parasites  are  found  in  the  intestines  in  large 
quantities.  The  eggs  are  0.05  mm.  long  and  0.02  mm. 
broad,  are  oval  and  more  pointed  at  one  end  than 
at  the  other.  They  have  an  edge  with  a  doiible 
contour  (Fig.  49) .  The  worm  often  leaves  the  in- 
testine, and,  remaining  in  the  neighborhood  of  the 
anus,  evokes  a  most  troublesome  itching. 


Fig.  48. 
Egg  of  Ascaris 

Lr.MBEICOIDES. 


Fig.  49. 
Egg  of  Oxtceis 


VEKMICTJLAKIS. 


Anchylostoma  duodenale  is  diagnostically  of  the  greatest 
importance,  because,  by  its  constant  sucking  of  blood  from 
the  w^alls  of  the  intestine,  it  produces  a  profound  anaemia 
which  may  resemble,  in  its  clinical  course,  a  <jase  of  perni- 
cious anaemia. 

Anchylostoma  is  seen  in  brickmakers,  miners,  and  work- 
ers in  tunnels,  and  -when  an  anaemia  presents  itself  in 
laborers  of  this  class,  the  faeces  must  ahvaj^s  be  examined 


260 


ANIMAL   AND   VEGETABLE   PARASITES 


CHAP. 


Fig.  50. 
Egg  of  Anchylostoma 

DUODENALE. 


for  anchylostoma.     As  long  as  no  anthelmintic  is  adminis- 
tered, only  the  eggs  are  fonnd  in  the  stools. 

The  male  is  from  8  to  12  mm.,  the  female  from  10  to  18  mm. 

long.  The  male  has  a  three-lobed  tail,  the  female  a  pointed,  conical 
tail.  The  cephalic  end  is  provided  with  a 
bell-shaped  mouth-capsule  which  contains 
four  claw-like  teeth.  The  eggs  (Fig.  50)  are 
0.05  mm.  long  and  0.03  mm.  broad.  They 
have  a  smooth  surface  and  in  the  interior  sev- 
eral segmentation  bodies  are  visible.  If  the 
ovules  are  not  absolutely  recognizable  at  first, 
the  fseces  may  be  allowed  to  stand  in  a  warm 

place  for  2  or  3  days,  when  microscopic  examination  will  disclose 

in  anchylostoma  eggs  a  decided  increase  in  the  segmenting  process ; 

or  the  patient  may  be  given  an  anthelmintic, 

such  as  the  extract  of  felix  mas,  in  order  to 

establish  the  diagnosis  by  the  appearance  in 

the  faeces  of  the  parasite  itself. 

Trichocephalus  dispar  (Fig.  51)  is  found 

in  the  large  intestine,  and  is  not  of  great 

diagnostic  importance.     The  male  is  4  cm., 

the  female  5  cm.  long.     The  eggs,  0.06  mm. 

long  and  0.02  mm.  broad,   appear  in  large 

numbers  in  the  stools,  are  brown  in  color,  and  are  closed  at  each 

pole  by  a  shining  cover. 

Trichina  spiralis  is  fonnd  in  the  hnman  body  in  the  mus- 
cles and  in  the  intestines.  By  the  eating  of  improperly 
cooked,  trichinous  pork,  the  trichinae  reach  the  human 
stomach  and  intestine.  Here  the  capsule  containing  them 
is  dissolved  and  males  (1.3  mm.  long)  and  females  (3  mm. 
long)  become  free,  and  multiply.  In  the  course  of  from  5 
to  7  days,  the  young  trichina?  work  their  way  through 
the  intestinal  wall,  enter  the  blood-current,  and  are  carried 
into  the  muscles,  where  they  may  become  encapsulated 
(Fig.  52).  The  diagnosis  of  trichinse  is  established  by  the 
appearance  of  the  parasite  in  the  faeces  after  the  adminis- 
tration of  anthelmintics  —  although  this  is  rarely  accom- 
plished —  or  by  the  finding  of  trichinae  in  the  muscles.    The 


Fig.  51. 
Egg  of  Trichocephalus 

DISPAR. 


XII  ANIMAL   AND    VEGETABLE   PARASITES  261 

symptoms  of  inspection  by  trichinae  depend  upon  the  stage 
of  the  disease.     If  the  parasites  are  still  in  the  intestines, 
the  s^^mptoms  of   a  gastro-enteritis  pre- 
sent themselves  ;  if  they  have  reached  the 
muscles,  multiple  abscesses  in  these  organs 
appear. 

Anguillula  intestinalis  (Rhabdonema  strou- 
gyloides,  Leuckart)  are  '2.25  mm.  long,  with 
romided,  obliquely  striped  bodies,  and  appear 
in  large  numbers  in  the  small  intestine.  The 
eggs  bear  a  striking  resemblance  to  those  of 
anchylostoma  duodenale,  and  a  differentiation 
between  the  eggs  of  these  species  may,  occa-  ^^^-  ^2. 

sionally,    be   of   importance.      They   are   not      Trichina  i>-  Muscle. 
known  to  exert  any  injurious  influence. 

Filaria  sanguinis  occurs  chiefly  in  the  tropics,  evoking  hcematuria 
and  chyluria.  Great  numbers  of  the  embryos  ch'culate  in  the 
blood.  The  parasite  is  an  auto-mobile,  delicate  worm,  surrounded 
by  a  thin  membrane.  It  is  0.35  mm.  long  and  about  as  broad  as  a 
red  blood-cell.  In  the  sediment  of  the  urine  the  embryos  may  be 
found  in  abundance. 

Filaria  medinensis,  also  a  tropical  parasite,  is  a  very  long  (80  cm.), 
very  narrow  worm  (about  1  mm.  broad).  It  produces  a  severe 
furunculosis. 

Arthrozoa 

The  Jiearl-louse  (Pediculus  capitis),  the  body-louse  (Pediculus 
vestimenti  or  Corposis  liumaui),  and  the  crab-louse  (Pediculus 
pubis)  must  be  given  diagnostic  consideration,  since  through  their 
bites  eczema  and  excoriations  ma}^  be  evoked,  which  may  be  con- 
fused with  other  skin  diseases,  and  hence  be  wrongly  treated. 

ThQ  flea  (Pulex  irritans)  and  the  bed-bug  (Acanthia  Reticularis) 
must  be  mentioned  in  this  connection,  since  the  flea-bite  bears  some 
resemblance  to  patechiae,  and  may  occasionally  mislead  to  a  diag- 
nosis of  purpura.  The  wheals  arising  from  bed-bug  bites  look 
something  like  roseola. 

Acarus  scabiei,  the  itch-mite,  is  the  etiological  factor  of 
the  itch  or  scabies,  which  is  recognized  by  the  characteristic 
cuniculi  made  in  the  skin  by  the  female,  and  the  accom- 


262  ANIMAL   AND   VEGETABLE   PARASITES  chap. 

panying  eczema.  The  male  itch-mite  is  0.2  mm.  long, 
0.35  mm.  broad.  The  female  is  0.35  mm.  long,  0.5  mm.  in 
width.  Examined  microscopically,  the  itch-mite  bears 
some  resemblance  to  a  turtle  with  a  conical  proboscis  and 
eight  legs. 

Acarus  folliculorum,  the  pimple-mite,  is  found  among  the 
contents  of  hair-follicles  (comedones).  It  is  of  worm-like 
form,  0.02  mm.  broad,  0.1  mm.  in  length. 

IL    Vegetable   Parasites 
1.    Moulds  and  Fungi 

The  moulds  are  flowerless  plants  (cryptogamous)  without  stems 
or  leaves,  with  simple  foliage  (thallophytes).  The  foliage  consists 
of  simple  cells  without  nuclei  and  devoid  of  chlorophyll.  They 
never  multiply  hy  fisdon  but  by  the  formation  of  long  chains  of  cells 
(hyphce).  By  the  interbranching  of  these  chains,  a  dense  basket- 
work  may  arise  (mycelium).  Single  hyphae  show  peculiarities  of 
growth,  the  fruits  of  the  plants  developing  upon  them.  These 
fruits  are  called  spores  or  conidia.  According  to  the  manner  in 
which  the  fruit-bearing  hyphae  develop  from  the  mycelium  and 
the  manner  in  which  these  in  turn  form  the  conidia,  the  schizo- 
mycetes  are  divided  into  different  groups :  mucorince,  aspergillce, 
penicillia,  etc. 

The  saccharomycetes  do  not  form  hyphae  nor  mycelia ;  they  con- 
sist simply  of  single  cells  without  nuclei  or  chlorophyll.  They 
multiply  by  (jemmation.  A  bud  appears  on  the  surface  of  the 
mother-cell,  which  increases  in  size  and  finally  detaches  itself. 
Frequently,  large  masses  of  these  cells  cling  together  and  form 
colonies. 

There  are  intermediate  forms  between  the  moulds  and  fungi, 
which,  under  some  conditions  of  nutrition,  form  hyphae,  and  under 
other  circumstances  grow  in  colonies.  The  principal  member  of 
this  group  is  the  Saccliaromyces  or  Oidium  albicans  (Soor  fungus). 

Acliorion  S chortle inii,  the  parasite  of  favus,  was  the  first 
of  the  vegetable  parasites  of  man  to  be  recognized. 

Trichophyton  tonsurans  is  the  fungus  of  herpes  tonsurmis 
and  parasitic  sycosis. 


XII  ANIMAL   AND   VEGETABLE   PARASITES  263 

Both  of  these  fungi  have  mycelia  with  many  branches, 
with  distinctly  jointed  hyphse.  In  the  fungus  of  favus  the 
branches  usually  stand  at  right  angles. 

These  fungi  may  be  raised  in  characteristic  pure  cultures. 
A  typical  favus  or  herpes  may  be  brought  about  by  inocula- 
tion in  the  skin. 

Microsporon  furfur  is  the  parasite  of  Pityriasis  versicolor. 
The  proof  of  the  presence  of  this  fungus  is  of  diagnostic 
importance,  since  the  yellowish  scales  of  pityriasis  —  mostly 
seen  in  the  cachectic  diseases,  particularly  phthisis  —  may 
be  easily  taken  for  an  actual  pigmentation  of  the  skin. 
The  scales  of  pityriasis  are  easily  removed  and  show  under 
the  microscope,  particularly  well  upon  the  addition  of  a  few 
drops  of  caustic  potash,  an  entangled  mycelium  with  heaps 
of  shining  conidia. 

Aspergillus  and  mucorina  are  occasionally  found  in  the  external 
auditory  passages,  in  the  nostrils,  and  in  the  nasopharynx.  The 
diseases  they  call  forth,  however,  are  evoked  simply  in  a  mechani- 
cal manner  by  their  presence.  The  growth  of  fungi  in  the  lungs 
(pneumonomycosis  aspergillina)  is  usually  a  secondary  deposit  in 
necrotic  tissue  or  cavities  already  existing. 

Saccharomycetes  often  appear  in  the  fermenting  contents 
of  the  stomach,  mainly  in  cases  of  dilatation,  chronic  ca- 
tarrh, and  carcinoma.  By  the  action  of  this  fungus  sugar 
is  split  up  into  alcohol  and  carbonic  acid  gas. 

Thrush  fungus  (Saccharomyces  or  Oidium  albicans)  has  the 
power  of  producing  necrosis  of  pavement  epithelium,  and  is 
the  cause  of  the  grayish-white  membranous  deposits  on  the 
mucous  membrane  of  the  mouths  of  poorly  nourished  chil- 
dren and  profoundly  sick  people.  These  membranes  may 
arise  in  other  organs  of  the  body  provided  with  pavement 
epithelium,  as  the  oesophagus  and  vagina.  In  media  rich 
in  sugar  and  acid  in  reaction,  this  parasite  grows  in  pure 
culture,  as  in  the  stomach ;  in  alkaline  media,  as  in  the 
mouth,  it  grows  with  abundant  hyplune  and  conidia. 


264  ANIMAL   AND   VEGETABLE    PARASITES  chap. 

2.   Schizomycetes   (Bacteria) 

In  the  category  of  these  minute  beings  (micro-organisms) 
belong  the  producers  of  the  infectious  diseases.  In  the 
cases  of  some  of  the  infectious  diseases,  the  clinical  demon- 
stration of  the  specific  micro-organism  is  indispensable. 

Biology  of  Bacteria 

The  bacteria  constitute  the  lowest  plane  of  vegetable  life.  They 
appear  in  the  following  forms  :  — 

1.  Micrococci  or  round  bacteria  are  arranged  in  chains  {strepto- 
cocci), or  in  grape-like  bunches  {staphylococci),  or  in  pairs  {diplo- 
cocci). 

2.  Bacilli  or  rod-shaped  bacteria  may  appear  with  curves  {vi- 
briones  or  comma  bacilli),  or  they  may  grow  into  long  chains 
(leptothrix). 

3.  Spirilla,  screw  form. 

A  dense  mass  of  bacteria,  bacilli,  or  cocci  is  known  as  a  zoogloßa 
mass. 

Bacteria  multiply  by  successive  fission.  Many  bacteria,  how- 
ever, increase  by  spores.  In  the  mother  bacterium  a  granular, 
strongly  refracting  area  becomes  differentiated,  is  freed,  and  grows 
into  a  new  bacterium.  The  spores  represent  the  permanent  form 
of  the  bacteria,  which  die  very  soon  upon  the  application  of  a 
moderate  degree  of  heat  (50°  to  60°  C.)  or  under  the  influence  of  a 
somewhat  concentrated  antiseptic  solution  (3  per  cent,  solution  of 
carbolic  acid).  The  spores,  however,  are  very  resistant  to  every 
external  influence,  and  can  be  killed  with  certainty  only  after 
being  subjected  for  half  an  hour  to  the  influence  of  boiling  water, 
or  for  3  hours  to  a  dry  heat  of  110°  C.  The  spores  are  not 
rendered  innocuous  with  certainty  by  the  usual  dilutions  of  anti- 
septic solutions.  Pathogenic  and  non-pat hor/enic  bacteria  are  dis- 
tinguished. The  latter  do  not  develop  in  the  human  body,  but 
thrive  on  dead  material  (as  saprophytes),  lirodnc'ing fermentation  and 
putrefaction. 

Pathogenic  bacteria  thrive  in  the  bodies  of  man  and  the  lower 
animals,  producing  the  infectious  diseases :  some  of  them,  however, 
like  the  anthrax  bacillus,  can  live  on  dead  material.  This  variety 
is  called  ectogenous  ov  facultalire. 


XII  ANIMAL   AND    VEGETABLE   PARASITES  265 


The  Demonstration  of  Bacteria 

For  clinical  purposes  the  main  examinations  of  bacteria 
are  confined  to  pus,  sputum,  aspirated  fluids,  faeces,  and  blood ; 
for  such  study  the  mounting  and  staining  of  dry  specimens 
is  sufiiciently  satisfactory.  In  some  cases,  however,  this 
method  does  not  suffice,  and  the  preparation  of  a  pure  cul- 
ture {Koch)  or  animal  inoculation  must  be  resorted  to. 

The  preparation  of  a  dry  specimen.  A  small  particle  of  the  sub- 
stance to  be  examined  is  placed  upon  a  perfectly  clean  cover  glass, 
upon  which  another  cover  glass  is  then  placed  with  great  care. 
The  two  cover  glasses  are  then  repeatedly  drawn  over  each  other 
in  order  to  get  as  fine  a  layer  as  possible  on  either  glass.  It  is 
then  allowed  to  dry  as  thoroughly  as  possible  in  the  air,  the  pre- 
pared surface,  of  course,  lying  uppermost.  The  cover  glass  is  then 
seized  with  a  forceps  and  is  passed  two  or  three  times  horizontally 
through  the  flame  of  a  Bunsen  burner  or  an  alcohol  lamp.  This 
is  for  the  purpose  of  coagulating  the  albumin  present.  The  speci- 
men may  now  be  subjected  to  the  staining  fluid. 

If  one  wishes  to  make  a  hasty  examination,  the  substance  to  be 
examined  may  be  transferred  at  once  to  2^,  slide,  which,  after  heating 
in  the  flame,  may  be  further  treated  the  same  as  the  cover  glass. 

The  staining  of  a  dry  specimen.  Alcoholic  solutions  of  the  basic 
aniline  dyes  must  be  kept  at  hand.  The  main  ones  are  Bismarck 
brown,  methylene  blue,  methyl-violet  or  gentian-violet,  fuchsin 
(red),  and  malachite  (green).  To  prepare  these  solutions,  the 
crystalline  powder  of  the  dyes  is  dissolved  in  alcohol  in  excess, 
thoroughly  shaken,  allowed  to  stand  several  hours,  and  filtered. 
Four  or  five  drops  of  the  saturated  alcoholic  solution  are  placed  in 
a  watch-glass  full  of  distilled  water.  The  dry  specimen  is  placed 
into  this  solution,  the  prepared  side  down,  for  from  2  to  4  min- 
utes. It  is  then  washed  in  water,  dried  between  two  pieces  of 
filter  paper,  laid  upon  the  slide  in  oil  of  cloves  or  Canada  balsam, 
and  is  examined  under  the  microscope.  An  oil  immersion  objective, 
an  open  diaphragm,  and  an  Abbe  condenser  are  essential  for  a  proper 
bacteriological  examination. 

In  order  to  stain  rapidly,  a  concentrated  watery  solution  may  be 
dropped  directly  upon  the  specimen.  Slide  preparations  are  always 
treated  in  this  manner,  the  staining  fluid  being  washed  off  with 
water.     They  are  mici'oscopically  examined  without  cover  glasses. 


266  ANIMAL   AND    VEGETABLE   PARASITES  chap. 

The  method  just  described  answers  ordinary  clinical  demands. 
The  aniline  dyes  stain  micro-organisms  and  the  nuclei  of  the  cells 
intensely ;  the  protoplasm  of  the  cell  is  usually  stained  very  weakly. 

By  staining  bacteria  by  Gram's  method,  they  can  be  isolated,  so 
far  as  coloring  is  concerned,  from  the  tissues  in  which  they  lie. 
This  method  consists  in  placing  the  cover  glass  preparation  in 
an  aniline-gentian-violet  solution  for  3  minutes  (see  below,  tuber- 
cle bacillus)  and  then  for  1  minute  in  a  solution  of  iodine  and 
iodide  of  potassium  (iodine,  1 ;  iodide  of  potassium,  2 ;  distilled 
water,  300).  Decolorization  is  effected  by  repeated  washing  in 
alcohol.  The  bacteria  appear  on  a  colorless  background,  stained 
bluish-black.  If  it  is  desired,  the  nuclei  of  the  cells  of  the  tissues 
may  be  stained  with  some  contrasting  aniline  color,  as  Bismarck 
brown  or  eosin. 

The  Staining  of  Tubercle  Bacilli 

1.  Ehrliches  method.  As  described  above,  a  dry  specimen  is  pre- 
pared from  the  sputum.  The  particle  selected  should  be  taken 
from  a  purulent  or  cheesy  part  of  the  sputum.  An  easy  way  to 
find  such  particles  is  to  pour  the  sputum  upon  a  blackened  plate 
or  a  piece  of  smoked  glass. 

The  staining  fluid  is  aniline-gentian-violet,  and  is  prepared  as 
follows :  a  saturated  solution  of  aniline  oil  is  made  with  10  times 
its  volume  of  water,  and  is  filtered.  An  alcoholic  solution  of 
gentian-violet  is  added  drop  by  drop  to  a  watch-glass  full  of  the 
clear  aniline  solution  until  a  shining  membrane  appears  on  the 
surface. 

The  specimen,  prepared  side  down,  is  placed  in  this  solution 
and  warmed  for  10  minutes  over  a  flame.  The  cover  glass  is 
then  removed,  washed  with  water  and  then  in  a  25  per  cent,  di- 
luted nitric  acid  solution  until  it  is  colorless.  Owing  to  its  te- 
nacity for  aniline  dyes,  the  tubercle  bacillus  alone  is  now  stained, 
the  other  bacteria  present  having  given  up  their  coloring  to  the 
acid.  To  stain  the  tissues,  the  cover  glass  is  laid  in  a  solution  of 
Bismarck  brown  for  from  2  to  3  minutes.  It  is  again  washed  in 
water  and  dried. 

The  tubercle  bacilli  are  stained  violet,  the  nuclei  brown. 

Instead  of  gentian-violet,  one  may  add  an  alcoholic  solution  of 
fuchsin  to  the  aniline  solution,  and  the  nuclei  may  be  stained  with 
methylene  blue  or  malachite.  In  this  event,  the  bacilli  will  be 
red,  the  nuclei  blue  or  green. 


XII  ANIMAL   AND    VEGETABLE    PARASITES  267 

2.  Fränkel-GabheCs  rapid  method.  The  following  solutions  must 
be  prepared :  — 

A.  Fuchsin,  1 
Alcohol,  10 
Carbolic  acid,  5 
Distilled  water,  100 

B.  Methylene  blue,  2 
Sulphuric  acid,  25 
Distilled  water,  100 

The  prepared  cover  glass  remains  10  minutes  in  solution  A,  is 
washed  in  water,  dried,  and  is  placed  for  5  minutes  in  solution  B. 
It  is  again  washed  in  water  and  dried.  The  specimen  should  now 
have  a  light  blue  color.  If  it  is  still  red  in  parts,  it  should  be  put 
into  solution  B  for  from  1  to  3  minutes,  washed,  and  dried.  It  is 
then  mounted  in  oil  of  cloves  or  Canada  balsam  and  examined. 
The  tubercle  bacilli  are  red ;  everything  else  in  the  field  is  blue . 
This  method  is  to  be  recommended  for  its  accuracy  and  its  clear 
results. 

The  Bacteria  of  Diagnostic  Importance 

The  bacteria  of  pus.  —  a.  Staphylococcus ;  is  arranged  in 
irregular  masses  ;  is  stained  by  all  the  aniline  dyes.  When 
a  pure  culture  shows  a  growth  of  yellow  colonies,  it  is  known 
as  Staphylococcus  pyogenes  aureus;  when  white  colonies 
are  formed  in  pure  culture,  the  germ  is  given  the  name  of 
Staphylococcus  pyogenes  albus.  It  may  appear  in  any  sup- 
purative process,  abscesses,  phlegmona,  purulent  inflamma- 
tions of  the  serous  membranes,  otitis,  osteomyelitis,  purulent 
inflammatory  conditions  following  typhoid  fever,  etc. 

h.  Streptococcus  ;  is  arranged  in  chains  and  occurs  in  many 
purulent  processes.  The  inflammatory  conditions  provoked 
by  the  streptococcus  are  more  intense  than  those  of  the 
staphylococcus,  and  have  a  tendency  to  make  deeper  in- 
roads upon  the  system. 

Streptococci  are  the  etiological  elements  of  erysipelas ; 
they,  as   well   as   the   staphylococci,   produce  the   various 


268 


ANIMAL  AND  VEGETABLE  PARASITES 


CHAP. 


forms   of    sepsis,   particularly  puerperal  sepsis.     They  also 
cause  endocarditis,  croupous  pneumonia,  etc. 

At  present,  the  different  varieties  of  streptococci  are  re- 
garded as  morphologically  identical,  differing  only  in  the 
degree  of  virulence  they  manifest.  The  virulence  of  a 
species  is  determined  by  animal  experimentation. 


Fig.  53.  —  Staphylococci. 


Gonococci  (Neisser)  (Fig.  55)  are  diplococci  arranged  like 
pairs  of  coffee-beans.  They  often  completely  fill  the  pro- 
toplasm of  pus-cells,  leaving  only  the  nucleus  free.  Appar- 
ently, they  are  to  be  found  only  in  the  pus  of  gonorrhoea 
or  of  gonorrhoeal  infection  (gonorrhoeal  conjunctivitis,  cys- 
titis, gonitis,  pleurisy,  and  endocarditis).  The  presence  of 
gonococci  is  accepted  by  most  specialists  as  a  proof  of  the 
correctness  of  diagnosis  in  doubtful  cases  of  urethritis  and 
leucorrhoea. 

Meningococci  (Diplococci  intracellulares)  ( Weichslehaum- 
Jäfjer)  are  diplococci  sha]3ed  like  a  roll,  chiefly  lying  within 


XII 


ANIMAL    AND   VEGETABLE    PARASITES  269 


Ky'\ 


*  fast  ■<     i-^:si,f^:,  :: 


Wi- . 


•    ^ 

*- 


i 


i 


Fig.  54.  —  Steeptococci. 


Fig.  55.  —  Goyococci. 


270  ANIMAL   AND   VEGETABLE    PARASITES  chap. 

the  cells,  resembling  gonococci,  abundantly  demonstrable 
during  life  in  cases  of  cerebro-spinal  meningitis  by  means 
of  lumbar  puncture. 

Pneumococci,  the  diplococcus  of  pneumonia  (A.  Fränkel) 
(Fig.  56),  are  lancet-shaped  diplococci  which  are  regularly 
found  in  the  fibrinous  exudate  of  lungs  affected  with  pneu- 
monia and  in  the  sputum  accompanying  pneumonia.  The 
microscopic  examination  usually  suffices  to  recognize  the 
pneumococcus  with  certainty ;  the  diagnosis  is  rendered 
more  certain,  however,  by  making  a  culture,  and  by  the 
inoculation  of  the  germ  into  rabbits  which  die  with  a  typi- 
cal septicaemia.  The  absence  of  the  pneumococcus  in  the 
sputum  argues  against  a  diagnosis  of  pneumonia ;  its  pres- 
ence does  not  make  the  diagnosis  absolutely  certain,  since 
it  is  also  found  in  the  sputum  of  healthy  individuals.  The 
presence  of  the  pneumococcus  in  the  pus  of  empyema  makes 
the  etiology  of  this  disease  dependent  upon  a  former  pneu- 
monia. The  pneumococcus  may  be  responsible  for  purulent 
processes  in  other  parts  of  the  body  (meningitis,  otitis,  sal- 
pingitis, etc.). 

Typhoid  bacilli  (Eberth)  (Fig.  57)  are  short  rods  with 
curved  ends.  They  are  found  in  patients  suffering  from 
typhoid  fever  in  the  characteristic  intestinal  ulcers,  in  the 
mesenteric  glands,  in  the  spleen,  and,  in  severe  cases,  they 
may  be  found  in  other  organs  as  well  as  in  abscesses  devel- 
oping late  in  the  disease.  From  the  time  of  the  beginning 
of  the  separation  of  the  crust  of  the  intestinal  ulcer,  typhoid 
bacilli  may  be  found  in  the  stools.  The  ordinary  cover-glass 
preparation  is  not  characteristic,  however,  and  even  the  usual 
culture  methods  are  unsatisfactory,  because  the  bacterium 
coli  is  almost  identical  in  culture  with  the  typhoid  bacillus. 

Typhoid  bacilli  and  the  bacterium  coli  grow  upon  the  culture 
medium  —  suggested  by  Eisner — of  potassium  lodide-ipotüto-gelatme, 
in  differential  forms,  while  the  other  bacteria  of  the  f feces  do  not 
develop  thereon.     By  Elsner\<i  method,  the  diagnosis  of  typhoid 


XII 


ANIMAL    AND   VEGETABLE    TARASITES 


271 


,*  r:  , 


\*' 


<*i 


Fig.  56.  —  Pneumococci. 


Fig.  57. —Pure  culture  of  Typjioid  Batilli. 


272  ANIMAL   AND   VEGETABLE    PARASITES  chap. 

fever  may  often  be  established  by  the  bacteriological  examination 
of  the  faeces  in  from  24  to  48  hours. 

Very  recently  it  has  been  shown  that  the  blood-serum  of  ani- 
mals which  have  been  immunized  against  typhoid  bacilli  possesses 
the  specific  property  of  affecting  typhoid  bacilli  in  such  a  manner 
that  their  motion  is  inhibited,  that  they  resolve  themselves  into 
clumps,  and  become  finally  disintegrated  (agglutination,  Pfeiffer, 
Gruber).  The  blood-serum  of  persons  suffering  from  typhoid  fever 
has  the  same  property  (Widal).  WidaVs  reaction  for  the  diagnosis 
of  typhoid  fever  consists  in  the  fact  that  when  a  drop  of  blood- 
serum  taken  from  a  typhoid  patient  is  mixed  with  a  small  quantity 
of  a  bouillion  culture  of  the  typhoid  bacillus,  placed  in  a  hanging 
drop  under  the  microscope,  and  then  observed,  agglutination  occurs. 
The  same  reaction  may  be  obtained  when  a  drop  of  such  blood  is 
added  to  a  24-hour  old  bouillion  culture  of  this  bacillus  in  a  test- 
tube,  and  the  same  placed  for  12  hours  in  a  thermostat.  It  is  then 
examined  for  agglutination.  However,  the  proportion  of  serum 
to  bouillion  culture  must  always  be  less  than  1  to  25.  Up  to  the 
present  time,  it  would  appear  as  though  a  positive  reaction  occurs 
only  in  typhoid  fever. 

Bacterium  coli  commune,  short  rods,  scarcely  to  be  dis- 
tinguished from  typhoid  bacilli  on  a  cover-glass  preparation 
or  in  the  ordinary  culture,  is  found  in  abundance  in  the 
contents  of  the  large  intestine  of  man.  It  may  produce  any 
inflammatory  or  purulent  condition  "which  appears  in  the 
neighborhood  of  the  intestines  or  the  genito-urinary  tract 
(peritonitis,  appendicitis,  abscess  of  the  liver,  cystitis,  pyel- 
itis), a.nd  may  even  lead  to  a  general  sepsis. 

Cholera  bacilli  (Koch)  (Fig.  58)  are  short,  curved  rods 
(comma  bacilli,  vibriones).  They  are  found  in  great  quan- 
tities in  the  stools  of  cholera  patients.  A  diagnosis,  how- 
ever, cannot  be  made  from  these  bacilli  except  in  culture; 
for  some  similarly  shaped  saprophytes  may  also  appear  in 
the  faeces. 

The  diagnosis  of  Asiatic  cholera  can  be  made  certain  only 
by  the  demonstration  of  the  presence  of  the  specific  micro- 
organism. AVith  a  platinum  needle,  a  Avhitish  particle  of 
mucus  is  selected  from  the  suspected  stool  and  is  shaken  in 


xii  ANIMAL    AND    VKGETABI.E    I'AIJ ASITES  273 

a  test-tube  with  melted  gelatine ;  frojii  this  test-tube  a  sec- 
ond one,  also  containing  melted  gelatine,  is  inoculated  with 
a  platinum  loop.  l)oth  test-tuV)es  are  emptied  into  Petri 
dishes.  Upon  the  hardening  of  the  gelatine,  these  dishes 
are  kept  at  a  temperature  of  22°  C.  in  the  thermostat.  In 
from  24  to  48  hours  the  colonies  of  cholera  bacilli  are  recog- 
nizable.    They  liquefy  the  gelatine,  and,  by  so  doing,  form 


Fig.  58.  —  Pukk  Culturk  of  Oiioi-kka  Bacii.t.i. 

characteristic,  funnel-shaped  depressions.  AVith  a  low  mag- 
nifying power,  the  individual  colonies  may  be  distinguished 
by  their  weak  lustre,  by  their  arrangement,  which  bears  a 
resemblance  to  fragments  of  broken  glass,  and  by  their 
irregular  edges.  The  depressions  in  the  gelatine  are  more 
clearly  seen  when  the  micrometer  screw  is  employed. 

If  there  are  but  few  vibrios  microscopically  demonstrable  in 
the  faeces,  the  plate-culture  method  of  SchoUelius-Koch  must  be 
employed.  A  small  quantity  of  faeces  is  placed  \u  a  nutritive 
culture  luedium   of    1   per  cent,  peptone  and  \  per  cent,  sodium 


274 


ANIMAL   AND   VEGETABLE   PARASITES 


CHAP. 


chloride.  Iii  the  thermostat  these  vibrios  increase  much  more 
extensively  in  this  medium  than  the  other  fsecal  bacteria.  As  a 
result  of  their  need  for  oxygen,  they  accumulate  on  the  surface, 
where  they  form  a  film  in  about  12  hours.  A  small  particle  of  this 
film  is  then  inoculated  on  a  gelatine  plate. 

In  addition  to  the  culture  method,  experiments  on  animals  assist 
in  the  diagnosis.  The  Pfeiffer  reaction  is  differentially  diagnostic : 
cholera  bacilli  rapidly  die  in  the  peritoneal  cavity  of  highly  immu- 
nized guinea-pigs.  The  smallest  quantity  of  the  blood-serum  of 
highly  immunized  animals  will  agglutinate  cholera  bacilli  (Gruher). 


( 


4 


•\ 


'^-i,'-*/ 

^^/M 


Fig.  59.  —  Bacilli  in  Tuberculak  Sputum. 


Tubercle  bacilli  (Koch)  (Fig.  59)  are  narrow  rods,  about 
three-fourths  of  the  size  of  a  red  blood-cell.  Their  staining 
reactions  are  characteristic  (see  p.  260).  The  presence  of 
tubercle  bacilli  in  an  organ  is  an  absolutely  certain  proof  of 
the  existence  of  tuberculosis  there.  They  are  found  in  the 
sputum  (pulmonary  tuberculosis),  in  the  urine  (tuberculosis 
of  the  genito-urinary  tract),  in  the  blood  (miliary  tubercu- 
losis), in  the  faeces  (tuberculosis  of   the  intestine),  in  pus 


XII 


ANIMAL   AND   VEGETABLE    PARASITES 


275 


(tuberculosis  of  the  bones,  empyema,  etc.),  and  in  the  skin 
(lupus). 

Tubercle  bacilli  in  the  ftfooh  of  tubercular  patients  may  be 
derived  from  sputum  which  has  been  swallowed,  and  do  not  indi- 
cate necessarily  tuberculosis  of  the  intestine. 

In  the  smegma  of  the  prepuce  and  labia,  are  many  short  rods 
which  give  some  of  the  characteristic  staining  reactions  of  tubercle 
bacilli  (Smegma  bacilli).    These  must  be  borne  in  mind  when  there  is 
a  suspicion  of  urogeni- 
tal tuberculosis.    They 
lose  their  color  in  abso- 
lute alcohol  ill  1  min- 
ute, while  tubercle  ba- 
cilli retain  their  stains 
for  several  minutes. 


The  spirilla  of  re- 
lapsing fever  (Ober- 
meier)  (Fig.  60)  are 
found  in  the  blood 
of  patients  suffering 
with  relapsing  fever. 
They  are  seen  only 
wdien  fever  is  pres- 
ent, and  with  a  high 
magnifying  power 
they  may  be  seen 
in  active  movement  when  unstained.  Cover-glass  prepara- 
tions may  be  stained  with  any  of  the  aniline  dyes. 

Anthrax  bacilli  (Davaine)  are  large,  thick  rods,  quite  easily 
recognized  in  a  cover-glass  preparation.  The  diagnosis  is 
rendered  certain  by  inoculation  upon  a  mouse,  wdiich  dies  in 
from  1  to  2  days  after  the  inoculation.  The  blood  of  the 
mouse  is  found  filled  to  overflowing  with  anthrax  bacilli. 
Diagnostically,  the  anthrax  bacillus  is  important  because  in 
man  it  is  productive  of  large  carbuncles,  the  specific  nature 
of  which  can  be  recognized  only  by  the  demonstration  of 
the  bacilli. 


Fig.    60.  —  Spirilla    from   a   Case   of   Relapsing 
Fever  dfring  the  Fetek. 


276  ANIMAL   AND    VEGETABLE    PARASITES  chap. 


Fig.  61.  —  Diphtheria  Bacilli. 

Diphtheria  bacilli  (Löffler)  (Fig.  61)  are  short,  narrow 
rods,  the  etiological  factors  of  diphtheritic  inflammation,  in 
which  a  deep  necrosis  of  the  mucous  membrane  goes  hand 
in  hand,  with  the  formation  of  a  membrane.  If  the  bacilli 
are  not  very  virulent,  they  may  call  forth  a  simple  catarrhal 
or  fibrinous  inflammation  of  the  mucous  membrane.  A  pure 
culture  of  diphtheria  bacilli  may  sometimes  be  obtained  by 
passing  a  small  piece  of  diphtheritic  membrane  over  several 
culture  plates  containing  solidified  blood-serum.  In  this 
culture  medium,  a  shining  surface  develops  in  two  days, 
which  on  microscopic  examination  of  stained  cover-glass 
preparations  shows  a  collection  of  short  rods. 

In  all  doubtful  cases  of  follicular  angina,  the  membrane 
must  be  examined  microscopically  and  by  means  of  cultures 
for  diphtheria  bacilli.  The  presence  of  bacilli  in  the  mem- 
branes settles  the  diagnosis. 

Glanders  bacilli  (Lößer)  may  be  found  in  profusion  in 
the  nodes  of  glanders ;  they  grow  on  potatoes  in  character- 


OTT 


XII  ANIMAL   AND    VEGETABLE    PAKASITES  li  M 

istic  brown  patches.  If  the  pus  of  glanders  or  a  pure 
culture  of  the  bacilli  is  injected  into  the  abdominal  cavity 
of  a  male  guinea-pig,  its  testicles  undergo  purulent  inflam- 
mation (Strauss). 

Influenza  bacilli  (Pfeiffer),  very  minute  rods,  are  contained 
in  great  numbers  in  the  bronchial  mucous  membrane  and  in 
pneumonic  foci  in  influenza.  Agar  is  a  good  culture  medium 
when  previously  covered  with  fresh  blood.  The  colonies 
develop  as  very  minute  drops,  as  clear  as  water  and  scarcely 
appreciable  with  the  naked  eye. 

Tetanus  bacilli  (Nicolaier-Kitasato)  are  demonstrable  in 
the  wounds  or  purulent  inflammations  which  usually  evoke 
tetanus.  The  demonstration  of  tetanus  bacilli  is  chiefly  of 
theoretical  interest  because  the  clinical  diagnosis  is  always 
easily  established. 

Actinomyces.  —  The  ray  fungus  is  of  diagnostic  impor- 
tance, since  it  is  the  etiological  factor  of  actinomycosis,  an 
infectious  disease  running  its  course  with  chronic  suppura- 
tion. The  ray  fungus  forms,  in  dense  masses,  yellowish 
granules  of  the  size  of  a  poppy.  On  microscopic  examina- 
tion, they  separate  into  chains  of  fungi  with  peripheral, 
club-shaped  enlargements,  resembling  a  bunch  of  grapes  in 
their  arrangement. 


CHAPTER   XIII 

THE   RÖNTGEN   RAYS   AS   DIAGNOSTIC   AIDS 

In  1895  Professor  Röntgen  of  Würzburg  discovered  that, 
by  the  discharge  of  induced  electric  currents  through  a  vac- 
uum tube  (Crookes's),  peculiar  rays  of  light  emanated  from 
the  cathode.  These  X-rays,  so  called  by  Röntgen,  possess 
the  remarkable  property  of  penetrating  solid  objects,  and  are 
not  subject  to  reflection  or  to  refraction.  Looked  at  through 
a  screen  covered  with  bario-platinum  cyanide,  in  a  dark 
room,  the  X-rays  evoke  a  bright  light;  upon  a  sensitive 
photographic  plate  they  produce  impressions  which  may  be 
developed  by  ordinary  daylight. 

The  more  solid  the  body,  the  greater  resistance  does  it 
offer  to  the  passage  of  the  Röntgen  rays.  AVood  is  more 
easily  permeable  than  metal,  and  paper  than  wood.  The 
muscles  of  the  human  body  allow  less  easy  passage  of  the 
rays  than  the  soft  parts,  and  the  bones  are  least  permeable. 

By  placing  the  human  body  between  a  Crookes's  tube  and 
the  screen  covered  by  the  bario-platinum  cyanide,  the  more 
solid  parts  of  the  body  a^^pear  upon  the  plate  as  dark 
shadows,  while  the  soft  parts  are  more  or  less  light,  depend- 
ing upon  their  respective  densities.  The  plate  thus  shows 
a  shadow-picture  of  the  interior  of  the  body  {actinogram), 
the  bony  apparatus  appearing  very  distinctly,  while  the 
organs  of  the  chest  and  abdomen  are  easily  recognized  in 
outline. 

If  the  body  is  placed  between  the  Crookes's  tube  and  a 
photographic  plate  enclosed  in  a  box,  the  soft  parts  appear 
dark  in  the  negative,  the  denser  parts  light.     The  positive 

278 


CHAP.  XIII  THE    RÖNTGEN   RAYS  279 

made  from  this  shows,  correspondingly,  the  bones,  etc.,  dark, 
the  soft  parts  more  or  less  light. 

Immediately  upon  the  announcement  of  the  discovery  of 
the  E-öntgen  rays,  they  began  to  be  employed  for  medical 
purposes,  and  although  scarcely  a  year  and  a  half  has 
elapsed  since  the  publication  of  this  phenomenon,  it  may  be 
said  that  by  its  aid  many  internal  diseases  can  be  diagnosti- 
cated early  or,  at  least,  that  a  diagnosis  can  be  placed 
beyond  doubt.  As  the  apparatus  is  comparatively  easy  to 
acquire  and  as  the  technic  of  its  use  is  not  difficult,  many 
physicians  are  experimenting  with  the  X-rays,  and  further 
advances  may  be  awaited  with  certainty. 

The  heart.  —  Dilatation  and  pericarditis  may  be  diagnosti- 
cated, as  the  size  of  the  heart  can  be  seen  with  the  aid  of 
the  rays.  The  contractions  of  the  heart  can  be  distinctly 
witnessed  upon  the  fluorescent  screen,  and  this  enables  us 
to  form  a  judgment  as  to  the  strength  and  rhythm  of  the 
cardiac  beat  which  can  be  substantiated  by  the  examination 
of  the  apex-beat  and  the  pulse. 

The  blood-vessels.  —  With  the  aid  of  the  Eöntgen  rays, 
calcification  of  the  arteries  can  be  recognized.  The  picture 
of  this  phenomenon  on  the  cadaver  is  very  striking,  but  it 
is  not  so  sharply  marked  in  the  living  subject.  A  more 
practical  use  can  be  made  of  the  fluoroscope  by  observing 
dilatation  of  the  arteries,  by  which  means  the  diagnosis  of 
aneurysm  of  the  aorta  may  be  made  much  earlier  than  has 
hitherto  been  the  case.  Aneurysm  of  the  aorta  has  been 
seen,  for  example,  before  any  local  symptoms  have  appeared. 
A  differential  diagnosis  from  other  mediastinal  tumors  can 
be  made  by  the  visible  pulsation. 

The  lungs.  —  The  lungs  are  visible  as  filling  the  thoracic 
cavity  as  a  weak  shadow,  and  their  size  can  thus  be  easily 
judged.  The  diagnosis  of  emphysema  can  thus  be  made 
without  further  difficulty.  Pleuritic  effusions,  adhesions, 
and  large  infiltrations  are  readily  recognized  by  the  deeper 


280  THE    RÖNTGEN  KAYS  chap,  xiii 

shadows  they  produce.  It  is  not  yet  certain  if  small  infil- 
trations whose  presence  we  have  as  yet  no  objective  methods 
of  demonstrating,  can  be  made  recognizable  by  means  of 
the  skiagraph. 

Tumors  of  the  lungs  or  of  the  pleurae  can  be  diagnosti- 
cated with  certainty  much  earlier  than  previously.  This 
is,  beyond  doubt,  an  important  step  in  the  progress  of 
diagnosis. 

The  abdominal  organs.  —  The  observations  so  far  upon  the 
abdominal  organs  have  not  been  very  satisfactory.  Large 
tumors  have  been  easily  seen,  but  an  early  diagnosis  of 
them  has  not  yet  been  accomplished.  It  is  frequently  im- 
possible to  differentiate  the  outlines  of  the  various  organs. 
The  oesojjhagus  and  stomach  can  be  more  readily  distin- 
guished by  the  preliminary  passing  of  a  stomach  tube  sur- 
rounded by  a  spiral  of  metal  or  filled  with  small  shot. 
Even  this  measure  has  not  furthered  diagnosis.  It  is  not 
yet  established  with  certainty  to  what  extent  renal,  vesical, 
or  biliary  calculi  can  be  demonstrated.  The  greatest  pro- 
gress has  been  made  in  the  use  of  this  new  photography  in 
the  diagnosis  of  diseases  of  the  bones  and  joints,  and  in 
demonstrating  the  presence  of  foreign  bodies.  In  these 
instances,  surgery  has  been  a  greater  gainer  than  medicine. 
For  internal  medicine,  the  presence  of  caries  of  the  vertehroi, 
the  bony  changes  of  rhachitis,  the  anchylosed  joints  and  the 
deformed  epiphyses  of  chronic  articular  rheumatism,  are  of 
importance.  It  would  seem  that  the  Röntgen  rays  will 
offer  a  means  of  making  a  differential  diagnosis  between 
gout  and  arthritis  deformans,  so  frequently  diificult  to 
determine. 


INDEX 


Abdomex,  20,  95;  diseases  of,  99; 
disteutiou  of,  95  ;  tumors  of,  98. 

Abduceus  paralysis,  47. 

Aearus  folliculorum,  262;  scabiei, 
261. 

Accessorius  paralysis,  47. 

Acetone  and  aceto-acetic  acid,  199. 

Achilles  tendon  reflex,  55. 

Achoriou  Schoenleinii,  262. 

Acid,  hydrochloric  test  for,  86 ;  hip- 
puric.  208 ;  lactic,  test  for,  86  ;  suc- 
cinic, 258 ;  sulphanilic,  201. 

Acoustic  nerve,  lesion  of,  45. 

Actinography,  278. 

Actinomyces,  150,  277. 

Adenoid  vegetations,  108. 

iEgophony,  141. 

Agony,  15. 

Agraphia,  50. 

Air,  complementary,  127 :  reserve, 
127;  residual.  127;  tidal,  127. 

Albumin,  qualitative  tests  of,  186; 
quantitative  test  of,  187  ;  albumino- 
meter,  187. 

Albuminuria,  185  :  cardiac.  161 ;  cy- 
clic, 186:  intermittent,  186;  physi- 
ological, 185 ;  spurious,  185. 

Albumosuria,  188. 

Alcoholism,  44,  50,  52. 

Alexia,  50. 

Alimentary  glycosuria,  195. 

Alloxan  bodies,  208. 

Amaurosis,  46. 

Ambylopia,  46. 

Ammonium  urate,  213. 

Amoeba  coli,  254. 

Amphoric  resonance,  134;  breath- 
ing, 138. 

Amygdallitis,  follicular,  29. 

Amyotrophic  lateral  sclerosis,  68. 


Auacidity,  76. 

Ansemia  250 ;  pernicious,  251 ;  sec- 
ondary, 252. 

Anaesthesia,  57  ;  of  pharynx,  109. 

Analgesia,  58. 

Anamnesis,  4. 

Anarthria,  49. 

Anatomy  of  brain  and  spinal  cord, 
38  seq'. 

Anchylostoma  duodenale,  259. 

Angina  follicularis,  29 ;  pectoris,  160. 

Anguillula  intestinalis,  261. 

Angulus  Ludovici,  123. 

Ankle  clonus,  55. 

Anode,  60. 

Anthrax,  bacillus  of,  275. 

Aorta,  aneurysm  of,  180;  insuffi- 
ciency of,  178 ;  stenosis  of,  178. 

Aortitis,  180. 

Apathy,  35. 

Apex-beat,  162:  displacements  of, 
162 :  systolic  retraction  of,  164. 

Aphasia,  49. 

Aphonia,  109,  118. 

Apncea,  9. 

Apoplexy,  43. 

Appendicitis,  98. 

Appetite,  76. 

Arsenic,  test  for.  217. 

Arterial  sounds,  170. 

Arterio-sclerosis,  179. 

Arthrozoa,  254,  260. 

Articular  sense,  59. 

Ascaris  lumbricoides,  259. 

Ascites,  96. 

Aspergilli,  150,  263. 

Asthma,  bronchial,  125;  cardiac, 
161;  crystals  of,  148;  dyspeptic, 
126;  nasal,  126;  ursemic,  126. 

Ataxia,  50. 


281 


282 


INDEX 


Atelectasis,  132. 
Athetoid  movemeuts,  53. 
Atrophy  in  paralysis,  42,  68. 
Auscultation  of  heart,  167 :  thorax, 

136 ;  vessels,  170 ;  voice,  141. 
Auscultatory  percussion,  134. 
Autoscopy,  113. 
Axillary  lines,  128. 

Bacilli,  264. 

Bacteria,  264. 

Bacterium  coli,  272. 

Basedow's  disease,  172,  240. 

Biedert's  method,  151. 

Biermer's  change  of  sound,  135. 

Biliary  colic,  104 ;  ducts,  catarrh  of, 
103. 

Biuret  reaction,  87. 

Bladder  epithelium,  214;  calculi  in, 
226 ;  cancer  of,  226 ;  tumors  of,  226. 

Blood,  241 ;  cells,  red,  243;  cells,  red, 
nucleated,  247 ;  cells,  measure- 
ments of,  245 ;  cells,  staining  of, 
246  ;  cells,  white,  244 ;  corpuscles, 
counting,  244 ;  diseases  of,  241,  250  ; 
examination  of,  242;  expectoration 
of,  142  ;  haemoglobin  in,  248 ;  in  the 
stool,  92;  in  the  urine,  189;  Plas- 
modium malariae  in,  27;  -poison- 
ing, 31 ;  reaction  of,  249 ;  specific 
gravity  of,  249 ;  spectroscopy  of, 
249;  tests  for,  189;  -vessels,  dis- 
eases of,  179  :  vomiting  of,  79. 

Blue  sputum,  145. 

Boas's  test  meal,  86. 

Böttcher's  test  for  sugar,  194. 

Bothriocephalus  latus,  256. 

Brachycardia,  171. 

Brain,  abscess  of,  67:  syphilis  of, 
67  ;  tumors  of,  67. 

Breast,  funnel-shaped,  123;  pigeon's, 
123  ;  wedge-shaped,  123. 

Bright's  disease,  220. 

Bronchial  casts,  144. 

Bronchiectasis,  152. 

Bronchitis,  151;  fetid,  157. 

Bronchophony, 141 . 

Broncho-pneumonia,  153. 

Bruit  de  pot  tele,  134. 


Bulbar  paralysis,  68. 

Bulimia,  76. 

Burdach,  columns  of,  41. 

Calculi,  biliary,  104 ;  biliary,  analy- 
sis of,  164  ;  cystin,  227  ;  renal,  225  ; 
vesical,  226;  vesical,  analysis  of, 
226;  xantbin,  227. 

Calomel  stool,  92. 

Caloric  necessity,  230. 

Caloric  value  of  food-stuffs,  231. 

Calves,  cramp  of,  52. 

Capillary  pulse,  178. 

Caput  Medusae,  97. 

Carbonate  of  lime,  212. 

Carbonic  oxide  blood,  250. 

Carcinoma  of  intestines,  100 ;  liver, 
104;  oesophagus,  74;  stomach,  90. 

Cardiac  area,  bulging  of,  163; 
asthma,  161 ;  impulse,  163 ;  mur- 
murs, 167  ;  oedema  of,  161 ;  thrills, 
164. 

Carotids,  sounds  in,  170. 

Casts,  bloody,  214:  bronchial,  144; 
brown,  214;  epithelial,  214  :  granu- 
lar, 214;  hyaline,  214:  waxy,  214. 

Catalepsy,  53. 

Catarrh  of  biliary  ducts,  103;  intes- 
tines, 99. 

Cathode,  60. 

Cavities,  134;  respiration  in,  135; 
symptoms  of,  135. 

Cell-breathing,  136. 

Cercomonas  intestinalis,  253. 

Cerebral  abscess,  67  :  syphilis,  67. 

Cestodia,  254. 

Charcot-Leyden  crystals,  148. 

Chest,  barrel- shaped,  123;  circum- 
ference of,  127  :  pain  in,  121. 

Cheyne-Stokes  breathing,  10. 

Chills,  17. 

Chlorosis,  250. 

Choked  disc,  45. 

Cholera,  bacilli  of,  96, 272 ;  stools  of, 
94. 

Choreic  movements,  53. 

Chylnria,  202. 

Circulatory  apparatus,  di.seases  of, 
160. 


INDEX 


283 


Cirrhosis  of  liver,  105. 

Cocci,  '2G4. 

Colic,  biliary,  104;  mucous,  99;  re- 
nal, 224. 

Collapse,  14;  temperature  in,  14. 

Color  of  the  f?eces,  91;  skin,  8;  spu- 
timi,  144;  urine,  182. 

Columns  of  Burdach,  41 ;  Goll,  41. 

Coma,  35. 

Comma  bacillus,  272. 

Complementary  air,  127. 

Complexion,  7. 

Concretio  pericardii,  179. 

Conjunctival  reflex,  54. 

Constipation,  93. 

Convulsions,  50;  clonic,  50;  local- 
ized, 52  ;  tonic,  50. 

Corset-liver,  103. 

Costal  breathing,  124. 

Costo-abdominal  breathing,  124. 

Cough,  111,  121;  varieties  of,  122. 

Cover-glass  specimens,  265 ;  staining 
of,  2Ü5. 

Cracked-pot  sound,  134. 

Cramp  of  leg,  52 ;  sterno-cleido-mas- 
toid,  52. 

Cranial  nerves,  45. 

Creraaster  reflex,  53. 

Crisis,  18. 

Crises,  gastric,  69. 

Croupous  pneumonia,  23,  150. 

Cryptogenic  sepsis,  109. 

Crystals  of  acid  phosphate  of  cal- 
cium, 212;  Charcot-Leyden,  148; 
of  fatty  acids,  148:  oxalate  of  cal- 
cium, 211. 

Curschmann's  spirals,  148. 

Curve  of  Ellis,  154  ;  Damoiseau,  154. 

Cyanosis,  8. 

Cyclic  albuminuria,  186. 

Cysticercus  cellulosae,  255. 

Cystin  calculi,  227. 

Cystitis,  225. 

Death,  signs  of,  15. 
Defervescence,  24. 

Degeneration,  reaction  of,  64;   com- 
plete, 66 ;  partial,  66. 
Delirium,  37. 


Dextrose,  192. 

Diabetes  mellitus,  196,  238,  239; 
metabolism  in,  238. 

Diagnostic  puncture,  154. 

Diameter,  costal,  123;  sterno-verte- 
bral,  123. 

Diaphragm,  paralysis  of,  48. 

Diarrhwa,  91,  9."5. 

Diastase,  72. 

Diazo-reaction,  200. 

Dicrotism,  174. 

Dilatation  of  heart,  165,  167. 

Diphtheria,  30 ;  bacillus  of,  276. 

Diphthongia,  110. 

Diplococci,  264. 

Diplopia,  46. 

Distoma  haematobium,  258;  hepati- 
cum, 258:  lanceolatum,  259. 

Dittrich's  plugs,  149. 

Diverticulum  of  oesophagus,  73. 

Dorsal  position,  5. 

Double  sensation,  58;  sounds,  171. 

Dropsy,  10 ;  cachectic,  11 ;  with  al- 
buminuria, 10 ;  with  cyanosis  and 
dyspnoea,  10. 

Drug  eruptions,  12. 

Dry  rales,  139. 

Dulness  over  lungs,  132 ;  sternum,  167. 

Dynamic  sense,  59. 

Dysentery,  94. 

Dyspepsia,  76,  82,  90;  nervous,  91. 

Dysphagia,  111. 

Dysphonia,  109. 

Dj  spnoea,  9 ;  expiratory,  125. 

Echinococcus,  257;  cysts,  257:  of 
liver,  105;  in  sputum,  150. 

Eclampsia,  51. 

Ehrlich's  stain  for  bacilli,  266 ;  diazo- 
reaction,  200. 

Einhorn 's  saccharimeter,  198. 

Elastic  fibres,  147. 

Electric  irritability,  59. 

Electricity,  cutaneous,  sensibility  to. 
59. 

Embryocardia,  172. 

Emphysema,  152. 

Empyema,  154;  meta-pneumonic, 
155. 


284 


INDEX 


Endocarditis,  acute,  32;  ulcerative, 
32. 

Enteritis  membrauacea,  100. 

Enterogenous  albumosuria,  188. 

Enteroptosis,  84. 

Eosinupile  cells  in  blood,  248;  spu- 
tum, 145. 

Epidemic  meningitis,  31. 

Epilepsy,  50. 

Epistaxis,  107. 

Epithelium,  alveolar,  145. 

Eructations,  76. 

Eruptions,  12. 

Erysipelas,  22 :  cocci  of,  267. 

Esbach's  album inometer,  187. 

Exacerbation,  16. 

Exanthemata,  11,  19. 

Exchange  of  food-stuffs,  232. 

Expectoration,  111. 

Expression,  6. 

Extra-pericardial  friction  sounds, 
170. 

Exudation,  hftmorrhagic,  155  ;  puru- 
lent, 155;  serous,  155. 

Face,  appearance  of,  7 ;  color  of,  7 ; 
expression  of,  7. 

Facial  paralysis,  47. 

Facies  composita,  6 :  decomposita,  6. 

Faeces,  91;  amount  of.  91 ;  estimation 
of,  91 ;  fat  in,  92 ;  nitrogen  in,  2-36; 
vomiting  of,  80. 

Falsetto  voice,  109. 

Faradic  current,  59. 

Fastigium,  18. 

Fatty  heart,  177  :  kidney,  222. 

Favus,  fungus  of,  262. 

Features,  6. 

Fehling's  test  for  sugar,  194,  196. 

Femoral  artery,  double  sound  in, 
171. 

Fermentation  test  for  sugar,  194. 

Ferric  chloride  reaction,  200. 

Fever,  character  of,  19;  continuous, 
18:  course  of,  18:  intermittent,  18, 
27  :  inverted  type,  17  ;  malarial,  27  : 
recurrent,  25;  relapsing,  25;  re- 
mittent, 18;  scarlet,  21;  stupida, 
19;  symptoms  of,  18:  type  of,  18; 


typhoid,  24;  typhus,  25;  versatilis, 

19;  of  suppuration,  31. 
Fibrin,  143. 
Filaria  sanguinis,  261 :   medinensis, 

261. 
Flea,  261. 

Fleischl's  haemometer,  248. 
Flukes,  253,  258. 
Flushing,  7. 
Food,  metabolic    changes    in,   230; 

nutritive  value  of,  234. 
Forced  movements,  53. 
Fränkel-Gabbet's  staining  method, 

267. 
Friction    sounds,    extra-pericardial, 

170 :  pericarditis,  170 ;  pleural,  140. 
Fuliginous  lips,  20,  70. 
Functional  paralysis,  42. 
Fungi,  262. 
Funnel  chest,  123. 

Gabbet's  staining  method,  267. 

Gagging,  110. 

Gait,  50. 

Gall-stones,  104 ;  Cholesterin  in,  104. 

Galvanic  current,  examination  by,  60. 

Gangrene  of  lungs,  158. 

Garrod's  thread  test,  207. 

Gas,    escape    of,     into    abdominal 

cavity,  98. 
Gastric  crises,  69,  78. 
Gastritis,  acute,  90;  chronic,  91. 
Gastrodiaphany,  84. 
Gerhardt's  ferric  chloride  reaction, 

200 ;  change  of  sound,  135. 
Gibbus,  123. 
Gigantocytes,  247. 
Glanders,  bacillus  of,  276. 
Glenard's  disease,  84. 
Glossitis,  71. 
Glossopharyngeal    nerve,  paralysis 

of,  47. 
Glottis,  dilatation  of,  113;  spasm  of, 

116;  stenosis  of,  111. 
Glycosuria,  transitory,  195. 
Gmelin'stest,  104,  191. 
Goll's  columns,  41. 
Gonococci,  268. 
Gout,  240. 


INDEX 


285 


Gram's  stain,  266. 
Gubler's  hemiplegia,  44. 
Guiac  test  for  blood,  18S>. 
Gums  iu  lead-poisoning  72. 

Habitus,  5;  apoplecticus,  5;  neu- 
rasthenicus,  .") :  paralyticus,  125  : 
phthisic  us,  5. 

Haematemesis,  TH. 

Hfematoidin  crystals,  148. 

Hrematuria,  angioueurotic,  190;  of 
bleeders,  190. 

Hsemoglobiu,  estimation  of,  248. 

Hsemoglobinuria,  189,  191. 

Haemoptysis,  142. 

Hsemorrhagic  exudation,  155. 

Hsemosiderin  reaction,  147. 

Harrison's  furrow,  127. 

Hiiser's  coefficient,  182. 

Hay  fever,  126. 

Headache,  107  :  diffuse,  37  :  frontal, 
107. 

Heartburn,  76. 

Heart,  auscultation  of,  167 :  dilata- 
tion of,  165,  167  ;  diseases  of,  176  : 
disease,  urine  in,  176 ;  disease-cells, 
147;  displacement  of,  166;  dis- 
turbances of,  neurotic,  161 :  dul- 
ness  over,  165;  hypertrophy  of, 
166;  inspection  of,  162:  murmurs 
in,  168 ;  percussion  of,  165  ;  sounds, 
167;  sounds  accentuated,  168. 

Heller's  blood  test,  189;  test  for 
albumin,  187. 

Hemianopsia,  45. 

Hemianopic  iridoplegia,  46. 

Hemiplegia,  42;  embolic,  43;  apo- 
plectic, 43;  toxic,  43. 

Hemiopia,  45. 

Hemiopic  reaction  of  pupil,  46. 

Hepatization,  132,  153. 

Hepatogenous  albumosuria,  188. 

Herpes,  19. 

Hippuric  acid,  208. 

Hoarseness,  109. 

Hodgkin's  disease,  251. 

Hofmeister's  test  for  peptone,  188. 

Hydrobilirubin,  test  for,  192. 

Hydrochloric  acid,  tests  for,  86. 


Hydronephrosis,  225. 
Hyperacidity,  76,  84. 
Hyperesthesia,  57  ;  of  pharynx,  109. 
Hyperleucocytosis,  250. 
Hyperpyretic  temperature,  17. 
Hypertrophic  cirrhosis  of  liver,  105. 
Hypochondrium,  112. 
Hypoglossus  nerve,  paralysis  of,  47. 
Hypostatic  congestion,  1.32. 
Hypoxanthin,  208. 

Icterus,  7,  101 :  with  polycholia,  8; 
without  polycholia,  8;  gravis,  8, 
101 ;  simplex,  7,  101. 

Idiopathic  heart-disease,  176. 

Ileus,  95,  100. 

Imperative  movements,  53. 

Incubation.  19. 

Indican,  191,  208. 

Indigo  red,  test  for,  209. 

Infarct  of  lung,  haemorrhagic,  158; 
kidney,  hfemorrhagic,  224;  spleen, 
haemorrhagic,  10<j. 

Infectious  diseases,  pathognomonic 
symptoms  of,  19. 

Infiltration,  1.32. 

Influenza,  29;  bacillus  of,  277. 

Infusoria,  253. 

Insanity,  37. 

Inspection  of  heart,  162;  stomach, 
81 ;  thorax,  122. 

Intense  breathing  of  Kussmaul,  36. 

Intention  spasm,  52. 

Intermittent  fever,  18. 

Intestines,  carcinoma  of,  100 ;  ca- 
tarrh of,  99 ;  diseases  of,  91 :  ob- 
struction of,  95 ;  trichinae  in,  260. 

Jactitation,  6. 
Jaundice,  7, 101. 
Jendrassik's  trick,  55. 
Joint  sense,  58. 

Kidney,  amyloid,  223 :  atrophic,  223 
diseases  of,  220 ;  epithelium  of,  214 
fatty,  222  ;  haemorrhage  from,  190 
infarct  in,  haemorrhagic,  224;  pas- 
sive congestion  of,  223 ;  percussion 
of,  224  :  wandering,  225. 

Kjeldahl's  test  for  urea,  206. 


286 


INDEX 


Kreatiuin,  208. 
Kiihne's  peptone,  188. 
Kypho-scoliosis,  123. 
Kyphosis,  12o. 

Labzymogex,  89. 

Lactic  acid,  test  for,  86. 

LarjMix,  muscles  of,  113;  nerves  of, 
113 ;  pain  in,  111 ;  stenosis  of,  111 ; 
syphilis  of,  115 ;  tuberculosis  of, 
115  ;  tumors  of,  115. 

Laryngitis,  acute,  114;  chronic,  114. 

Laryngoscopic  examination,  112. 

Legal's  test  for  acetone,  200. 

Leptothrix  in  sputum,  147. 

Leucjemia,  hnnphatic,  251 ;  myelo- 
genous, 251;  splenic,  251. 

Leucin,  212. 

Leucocytes,  244 :  mononuclear,  247  : 
polynuclear,  248  ;  in  urine,  213. 

Leucocytosis,  250. 

Leyden's  crystals,  148. 

Lieben's  test  for  acetone,  200. 

Liebig's  test  for  urea,  205. 

Lips,  the,  70. 

Liver,  abscess  of,  104:  amyloid,  105; 
acute  yellovi'  atrophy  of,  104 :  car- 
cinoma of,  104 ;  chronic  congestion 
of,  105;  cirrhosis  of,  atrophic,  105; 
cirrhosis  of,  hypertrophic,  105 ;  dul- 
ness,  102, 103 ;  echinococcus  of,  105  ; 
movable,  103;  palpation  of,  102;  pas- 
sive congestion  of,  105 ;  j)ercussion 
of,  102;  venous  pulse  in,  164,  174. 

I^ivor,  9. 

Localization,  sense  of,  59. 

Locomotor  ataxia,  69. 

Lordosis,  123. 

Lungs,  abscess  of,  159;  anthracotic, 
145;  echinococcus  of,  159;  gangrene 
of,  158;  infarct  of,  h*morrhagic, 
158 ;  inflammation  of,  153 ;  per- 
cutory  limits  of,  129;  syphilis  of, 
159;  topography  of,  128;  tuber- 
culosis of,  156;  tumor  of,  15it; 
tympanitic  percussion  note  over, 
133;  vital  capacity  of,  126. 

Lymphocytes,  247. 

Lysis,  18. 


Macrocytes,  243. 

Malarial  fever,  27  ;  neuralgia,  29. 

Mamillary  line,  128. 

Maximum  thermometer,  17. 

Measles,  21. 

Measurement  of  blood  corpuscles,  245. 

Median  nerve,  paralysis  of,  48. 

Mediate  percussion,  1S4. 

Megalogastria,  84. 

Melancholia  attonita,  53. 

Membranous  enteritis,  100. 

Meniere's  disease,  37. 

Meningitis,  cerebro-spinal,  30;  epi- 
demic, 31 :  tubercular,  31,  67. 

Meningococci,  268. 

Mensuration,  127. 

Metabolic  balance-sheet,  237,  239. 

Metabolism,  anomalies  of,  233;  dis- 
orders of,  229 ;  equilibrium  of,  232  : 
nitrogenous,  232;  normal,  229. 

Metallic  note,  131. 

Metamorphic  respiration,  138. 

Metapneumonic  empyema,  155. 

Meteorism,  95. 

Methaemoglobin,  250. 

Methyl  reaction,  86. 

Microcytes,  243. 

Micrococci,  264. 

Micro-organisms,  264 ;  in  urine,  216. 

Microsporon  furfur,  263. 

Migraine,  46. 

Miliary  tuberculosis,  30. 

Milk,  test  meal  of,  85. 

Minute  thermometer,  17. 

Miserere,  80,  95. 

Mitral  insufficiency,  178:  stenosis, 
178. 

Mohrenheim's  space,  127. 

Monoplegia,  42. 

Moore"stest  (quantitative  for  sugar), 
196. 

Morbilli,  21. 

Morbus  Basedowii,  240;  Brightii, 
220;  maculosus,  11. 

Morning  vomiting,  80. 

Motor  irritation,  51 ;  paths,  38. 

Moulds,  262. 

Mouth,  71 ;  breathing,  108 ;  epithe- 
lium of,  145. 


INDEX 


287 


Movable  liver,  103;  spleen,  lOH. 

Movements  forced,  53. 

Miicorinse,  U()3. 

Mucous  membrane,  reflexes  of,  54. 

Multiple  sclerosis,  69. 

Mumps,  ol. 

Murexide  test,  207. 

Murmurs,  accidental,  169;  cardiac, 

168 ;  diastolic,  169 ;  functional,  1(59 ; 

presystolic,  169 ;  respiratory,  136 ; 

systolic,  169. 
Muscle  sense,  59. 
Musical  timbre  (cardiac),  168. 
Mydriasis,  47. 
Myelitis,  68;  cervicalis,  68 ;  dorsalis, 

()8 ;  lumbalis,  69. 
Myelogenous  leucaemia,  251. 
Myosis,  47. 

Myotonia  congenita,  52. 
Myotonic  reaction,  52. 
Myxcedema,  240. 

Nasal  voice,  110. 

Neck,  stiffness  in,  18,  31. 

Nematoidia,  259. 

Nephritis,  acute,  222;   chronic,  222; 

suppurative,  224;  urica,  211. 
Nephrolithiasis,  225. 
Nerves,  cranial,  45. 
Nervous  dyspepsia,  91;  system,  .33; 

system,  status  of,  33. 
Neuralgia,  57,  106 ;  malarial,  29. 
Neuritis,  44,  .50. 
Neuroses,  reflex  nasal,  108. 
Nipple  reflex,  54. 
Nitrogen  in  faeces,  236. 
Nitrogenous  equilibrium,  232. 
Nose-bleed,  107. 
Nose,  diseases  of,  107. 
Nutrition   and   strength,    condition 

of,  4. 
Nylander's  test  for  sugar,  194. 
Nystagmus,  53. 

Ochre,  yellow  sputum,  144. 
(Edema,  12. 
CEsophagoscopy,  73. 
Oesophagus,  carcinoma  of,  74 ;    di- 
verticula of,  73 ;  stricture,  72. 


Oesophagitis,  74. 

Oidiuni  albicans,  72,  263. 

Oil  test  (motility  of  stomach),  90. 

Opisthotonus,  51. 

Organic  heart  murmurs,  169. 

Otitis  media,  22. 

Ova  of  animal  parasites,  254  seq. 

Oxalate  of  lime,  211. 

Oxyuris  vermicularis,  259. 

Ozaena,  107. 

Pachydermia  laryngis,  116. 

Pain  sense,  58. 

Pallor,  7  ;  eximius,  7. 

Palpation  of  heart,  162 ;  stomach, 
81. 

Palsy,  lead,  72 ;  nuclear,  47. 

Paradoxical  contraction,  56. 

Paresthesia ,  57. 

Paralysis,  41 ;  abducens,  47  ;  agitans, 
53 ;  bulbar,  68 ;  cerebral,  67 ;  of 
children,  essential,  69;  of  cranial 
nerves,  45 ;  ci-ossed,  44;  diaphrag- 
matic, 48  ;  Erb's,  47  ;  facial,  47  ; 
functional,  41 ;  glosso-pharyngeal, 
47;  hypoglossal,  47;  intensity  of, 
49 ;  median,  48  ;  nuclear,  47  ;  oculo- 
motor, 46 ;  olfactory,  45  ;  optic, 
45;  peroneal,  48;  phrenic,  48; 
pneumogastric,  47  ;  posticus,  119 ; 
progressive  bulbar,  68 ;  radial, 
48 ;  recurrent,  46 ;  recurrent  laryn- 
geal, 119;  spinal,  47;  spinal  spas- 
tic, 68  ;  tibial,  48  ;  trigeminal,  47  ; 
trochlear,  47 ;  ulnar,  48 ;  vagus, 
48 ;  of  vocal  cords,  116. 

Paralytic  thorax,  122. 

Paraplegias,  42,  44. 

Parasites,  253. 

Parasternal  line,  128. 

Paresis,  41. 

Parotitis  epidemica,  31. 

Paroxysmal  hajmoglobinuria,  191 ; 
tachycardia,  171. 

Patellar  reflex,  55. 

Pathogenic  micro-organisms,  267. 

Pectoral  fremitus,  140. 

Pectoriloquy,  141. 

Pectus  carinatum,  123. 


288 


INDEX 


Pediculi,  261. 

Peliosis,  11. 

Penicillium  glaucuni,  262. 

Pepsin,  88. 

Peptone,  test  for,  188. 

Peptonuria,  188. 

Percussion  of  the  heart,  Kiö  ;  kidney, 
224;  liver,  102:  spleen,  106; 
stomach,  82;  thorax,  129. 

Pericardial  friction  sounds,  170. 

Pericarditis,  179. 

Perigastritis,  82, 

Period  of  expulsion,  163. 

Periomphalitis,  98. 

Peritoneum,  diseases  of,  91. 

Peritonitis,  96,  100:  chronic,  97, 100; 
perforation,  99. 

Perityphlitis,  98,  100. 

Pernicious  anaemia ,  251. 

Perturbatio  critica,  18. 

Pertussis,  122. 

Petechise,  12. 

Pfliiger's  test  for  urea,  205. 

Pharynx,  109 ;  hyperaesthesia  of,  109. 

Pharyngitis,  110. 

Phenyl  hydrazine  test  for  sugar,  195. 

Phosphate  of  calcium,  212. 

Phosphates,  triple,  212. 

Phosphatic  calculi,  226. 

Phthisis  pulmonum,  156. 

Physiological  albuminuria,  185 ;  gly- 
cosuria, 195. 

Pityriasis  versicolor,  263, 

Pleura,  adhesions  of,  140. 

Pleuritis  exsudativa,  154 ;  retrahens, 
155;  sicca,  154. 

Pneumococci,  270. 

Pneumonia,  23, 153 ;  congestive  stage 
of,  2.3. 

Pneumo-pericardiura,  166, 

Pneunio-thorax,  157, 

Pock-marks,  26,  27. 

Poikilocytes,  243, 

Polarization,  198. 

Poliomyelitis,  69. 

Portal  vein,  thrombosis  of,  97. 

Position  of  patient,  6, 

Posticus  paralysis,  119. 

Pregnancy,  77. 


Pressure  points,  57 ;  sense,  58. 

Presystolic  murmurs,  169. 

Prodromal  stage,  19  :  vomiting,  77. 

Proglottides,  254. 

Progressive  bulbar  paralysis,  68; 
spinal  atrophy  of  muscles,  42. 

Protozoa,  253,  254. 

Pseudo-crisis,  23. 

Pseudo-leucaemia,  251, 

Psychoses,  3(i,  37. 

Puerperal  albumosuria,  188. 

Pulmonary  artery,  insufficiency  of, 
179. 

Pulse,  the,  13,  171 ;  anacrotic,  174; 
arythmia  of,  172;  capillary,  178: 
curve,  174;  dicrotic,  174:  elastic 
elevation  of,  174;  excursion  of, 
175:  frequency  of,  19:  frequency 
of,  in  fever,  18:  hardness  of,  173; 
over-dicrotic,  174 ;  rapidity  of,  171 : 
rhythm  of,  172:  size  of,  173:  slow- 
ing of,  173 :  tension  of,  173 ;  ve- 
locity of,  173;  venous,  164. 

Pulse-wave,  174;  anacrotic,  174 ;  di- 
crotic, 174 ;  katacrotic,  174  ;  post- 
dicrotic,  174, 

Pulsus  alternans,  172:  bigeminus, 
172;  celer  et  altus,  173:  frequens, 
171 ;  paradoxus,  173  :  rarus,  171 ; 
trigeminus,  172. 

Pupil,  hemiopic  reaction  of,  46, 

Purulent  sputum,  142. 

Pus,  bacteria  of,  2(>4. 

Pyaemia,  31. 

Pj'elonephritis,  224. 

Pylorus,  hypertrophy  of,  82:  strict- 
ure of,  82. 

Pyogenic  alV)umosuria.  188, 

Pyramidal  tract,  40. 

Pj'^rosis,  76. 

Pyuria,  213. 

Rales,  139 ;  crepitant,  139 :  dry,  139 ; 
metallic,  140;  moist,  1.39;  ringing, 
139 ;  sibilant,  1.39 ;  sub-crepitant.  139. 

Raspberry  tongue,  20. 

Reaction  of  blood,  249;  urine,  183. 

Rectus  abdominis,  cramp  of,  51, 

Recurrent  fever,  spirilla  of,  275. 


INDEX 


289 


Rod  blood-colls,  24:5;  color  of,  244; 
imclo.-Ucd,  247  ;  nmnbor  of,  2415. 

RoMox,  ;il)doiiiiiial,  54;  Achilles 
toiidoii,  rtr) ;  «u'oin.ister,  54;  foot 
clonus,  55;  fuiictioüH,  5(5;  {jlntoal, 
54;  loss  of,  55;  niannllary,  54; 
patellar,  55;  i)lantai%  54  ;  skin,  54; 
tcMulon,  54. 

Reliexes,  .'55,  5)5;  abolition  of,  55. 

Relapsin;;-  f(*vei',  25  ;  spirilla  of,  275. 

lieniittent  fever,  18. 

Renal  hajniopbilia,  190. 

Reserve  air,  127. 

Residual  air,  127. 

IJespiration,  l.'5();  anii)horic,  l.'W; 
broncliial,  I'M;  broncbo-vesiculai', 
138;  cavernous,  i;)7  ;  costal  type, 
124;  costo-abdominal  type,  124; 
frequency  of,  124  ;  interrupted  or 
jerky,  137 ;  metamorphic,  138 ; 
puerile,  130;  slowinj;- of,  124;  sys- 
tolic, vesicular,  i;)() ;  tra.(!li(^!il,  137; 
uncertain,  138;  vesicular,  13(5; 
vesicular,  sbarpencMl,  i;5f). 

Respiratory  air,  127  ;  changes,  127; 
changes  in  sound,  135;  movements, 
124 ;  murmur,  136. 

Retropharyngeal  abscess,  10{). 

Rheumatism,  acute  articular,  .*?1, 

RhizojKxls,  253. 

Rhythmical  contractions,  52, 

Risus  sardonicus,  51. 

Romberg's  symptom,  50. 

R(intgen  rays,  278. 

Iloseola,  9. 

Kosenbach's  i-eaction  for  indigo  red, 
20'.). 

Rouleaux  formation,  243. 

Round  vv^orms,  2.59. 

Rubiginous  sputum,  144. 

Rubner's  test  for  sugar,  104. 

Sacchauimetkr,  Einhorn's,  108. 

Saccharomycetes,  2(52. 

Saliva,  72.  " 

Salkowski's  test  for  peptone,  180. 

Salol  test  of  motility  of  stomach,  80. 

Santonin  in  urine;,  210. 

Saprophytes,  264. 


Sarcina  puluKtnum,  146. 

Scapular  liiu;,  128;  retlex,  54. 

Scarlatina,  21. 

Schi/omycetes,  264. 

Sclerosis,  60. 

Scolex,  2.54. 

Scoliosis,  123. 

Scrurvy,  12. 

Secondary  anaemia,  2.52. 

Sedimentum  lateritium,  210. 

Semilunar  space,  83. 

Sensation,  disturbances  of,  57;   test 

of,  .58. 
Sensorium,  10,  .35. 
S(!nsory  i)aths,  40. 
Sepsis,  .31 . 
Septicjomia,  .32. 

Serous  sputum,  142;  exudation,  155. 
Side  position,  5  ;  pain  in,  121. 
Signs  of  death,  13. 
Singultus,  78. 
Skin,  bron/e  color  of,  8;  dryness  of, 

1.3;    reflexes  of,  54;    temperature 

of,  12. 
Small-pox,  2(5. 
Smegma  bacilli,  275. 
Sneezing,  ,5(5. 
Sodium  urate,  acid,  210. 
Soor,  72. 
Sound,  changes  in  auscultatory,  130; 

(puilities  of,  120. 
Spaces,  complementary,  130. 
Space  sense,  .58. 
Spasm,  50;  of  glottis,  11(5. 
Spastic  si)inal  paralysis,  (50. 
Speech,  centre  for,  40;  disturbances 

of,  40. 
Sphygmography,  174. 
Spinal  cord,  anterior  horns,  40;  pos- 
terior horns,  40. 
Spinal  muscular  atrophy,  68. 
Spinal  puncture,  30. 
Spine,  curvature  of,  122. 
Spirals,  Curschmann's,  149. 
Spirilla,  2(54,  275. 
Spirometry,  126. 
Spleen,   the,    10(5;    dulnoss   of,    106; 

enlargements  of,  in  malaria,  10(5; 

enlargement    of,    in    pneumonia, 


290 


INDEX 


106;  enlargement  of,  in  typhoid 
fever,  106;  floating  or  movable,  106. 

Splenic  leucaemia,  L'51. 

Spores,  formation  of,  264. 

Sporozoa,  253. 

Sputum,  bacteria  in,  146 ;  black,  145 ; 
bloody,  142  :  blue,  145 ;  Cholesterin 
crj-Btals  in,  149;  color  of,  144; 
cylindrical  epithelium  in,  145  ; 
echinococcus  in,  150;  eosinophile 
cells  in,  145;  examination  of,  141 ; 
fibrinous,  143;  green,  144  ;  heart- 
disease-cells  in,  146;  leptothrix 
in,  146;  leucocytes  in,  145;  muco- 
purulent, 142;  mucous,  142;  ochre- 
yellow,  144 ;  odor  of ,  144  ;  pavement 
epithelium  in,  145;  purulent,  142; 
quantity  of,  145;  red,  145;  red 
blood-cells  in,  146 ;  rubiginous,  144 ; 
rusty,  144;  sarcina  pulmonum  in, 
146 ;  serous,  142  ;  staining  reactions 
of,  145;  tyrosin  crystals  in,  150; 
yellow,  145. 

Stadium  decrementi,  18  ;  increment!, 
18. 

Stage  of  eruption,  19 ;  incubation,  19. 

Staphylococci,  267. 

Status  praesens,  2. 

Stenosis  of  aorta,  178;  bronchi.  111; 
larynx.  111 ;  oesophagus,  72 ;  tra- 
chea, 111. 

Sternal  line,  128. 

Sterno-cleido-mastoid  muscle,  cramp 
of,  51. 

Sterno-vertebral  diameter,  124. 

Sternum,  123;  anomalies  of ,  123. 

Stertor,  14. 

Stomach,  acid  determination  of,  86; 
ballooning  of,  84 :  carcinoma  of,  90 ; 
catarrh  of,  90 :  contents,  85 ;  con- 
tents, examination  of,  85  ;  dilata- 
tion of,  32,  84,  90;  diseases  of,  75; 
distention  of,  84;  free  acid  in,  86; 
inspection  of,  81 ;  motor  power  of, 
89;  pain  in,  76;  palpation  of,  81; 
peptone  in,  87;  percussion  of,  82; 
pressure  and  fulness  in,  76;  sar- 
cina in,  76;  total  acidity  of,  87; 
tumor  of,  82 ;  ulcer  of,  90. 


Stomatitis,  72. 

Stool,  black  color  of,  92 ;  particles  of 

tissue  in,  93;  green  color  of,  92  ; 

grayish- white  color  of,  92 ;  mucus 

in,  92;  pus  in,  92. 
Strabismus,  convergent,  47 ;   diver- 
gent, 47. 
Strength,  estimation  of,  4. 
Streptococci,  267. 
Stridor,  110. 
Stupor,  35. 

Subfebrile  temperature,  17. 
SuccussioHippocratis,  140. 
Suffusions,  12. 
Sugar,    qualitative    test    for,    193  ; 

quantitative  test  for,  196. 
Sugillations,  12. 
Sulphanilic  acid,  201. 
Sulphuric  ether,  203. 
Suppuration,  fever  of,  31. 
Swallowing,  sound  of,  74. 
Sweat,  12. 

Symptoms,  striking,  14. 
Syphilis,    cerebral,    67  ;    laryngeal, 

115 ;  of  lung,  159. 
Systolic   murmurs,   169;    retraction 

of  apex,  164 ;  vesicular  respiration, 

136. 

Tabes  dorsalis,  69. 

Tachycardia,  160,  171. 

Tactile  sense,  58 ;  test  of,  58. 

Tsenia  cucumerina,  257;  echinococ- 
cus, 257;  mediocanellata,  255  ;  nana, 
257  ;  solium,  254. 

Tape-worms,  254. 

Teeth,  the,  71. 

Teichmann's  blood  crystals,  249. 

Temperature,  hj-perpyretic,  17  ; 
measurement  of,  17;  sense,  59; 
of  skin,  12. 

Tendon  reflex,  53. 

Test  meals,  86. 

Tetanus,  51 ;  bacillus  of,  277. 

Tetany,  51. 

Thermometers,  16. 

Thoma-Zeiss  blood-counting  appara- 
tus, 244. 

Thomsen's  disease,  52. 


INDEX 


291 


Thorax,  auscultation  of,  136 ;  dila- 
tation of,  123;  flattening  of,  123; 
inspection  of,  122 ;  measurements 
of,  124 ;  narrowing  of,  123 ;  per- 
cussion of,  129. 

Thread  worms,  259. 

Thrills,  cardiac,  164. 

Throat,  the,  109. 

Thrush,  72,  263. 

Thyreoid  gland,  diseases  of,  240. 

Tic  convulsif,  142. 

Tidal  air,  127. 

Time  of  closure,  163. 

Titration,  197. 

Tongue,  the,  71 ;  inflammation  of,  71. 

Tonic  convulsions,  50. 

Tonsils,  the,  109. 

Topography  of  lung,  129. 

Tracheal  respiration,  111 ;  stenosis, 
111. 

Transitory  glycosuria,  195. 

Trematoda,  258. 

Tremors,  52. 

Tremor,  intention,  .52;  of  eye,  53; 
senilis,  52. 

Triacid  mixture,  144. 

Trichinae  spiralis,  260;  intestines, 
260  ;  in  muscle,  260. 

Trichocephalus  dispar,  260. 

Trichophyton  tonsurans,  262. 

Tricuspid  insufficiency,  178. 

Trigeminus  paralysis,  47. 

Triple  phosphates,  212. 

Trismus,  51. 

Trommer's  test,  193. 

Trousseau's  phenomenon,  51. 

Tubercle  bacilli,  274;  staining  of, 
266. 

Tubercular  meningitis,  67. 

Tuberculin,  156. 

Tuberculosis,  acute  miliary,  30. 

Tumor  of  kidney,  225 ;  of  stomach, 
82. 

Tympanitic  percussion  note,  133. 

Typhoid  fever,  24  ;  bacillus  of,  270  ; 
uncertain  stage,  24, 

Typhus  abdominis,  24 ;  exanthemati- 
cus,  25;  fever,  25. 


Uffelmann's  reagent,  86. 

Ulcer  of  stomach,  90. 

Ulcus  ventriculi,  90. 

Urates,  acid  sodium,  210. 

Uraemia,  51. 

Urea,  204 ;    demonstration   of,   205 ; 

quantitative     determination      of, 

205  seq. 
^Uric  acid,  207  ;  calculi,  226 ;  crystals, 

Urine,  albumin   in,  185;   albumoses 
in,  188;  acid,  183;  acid,  sediment 
in,  210;  alkaline  reaction  of,  184; 
alkaline  sediment  in,  212;  alloxan 
bodies  in,  208;   ammonia  in,  202; 
antifibrin   in,   218;    antipyrin   in, 
218;  arsenic  in,  217;  biliary  color- 
ing matter  in,   191;   bilirubin  in, 
191;    blood  in,   189;    bromine   in, 
216  ;  carbolic  acid  in,  209,  218 ;  car- 
bonates   in,  202  ;    casts   in,    214  ; 
chlorides  in,  202  ;    cloudiness  of, 
183;  color  of,  182;  cystin  in,  211; 
diminution    in    amount    of,    181 ; 
examination  of,  181;   fat  in,  202: 
ha;moglobin  in,  189,  191 ;  hippuric 
acid    in,   208;    hydrobilirubin   in, 
192 ;  in  fever,  18 ;  in  heart-disease, 
176;    increased   amount    of,   182  ; 
indican  in,  191,  208;  test  for  indi- 
can  in,  209;    iodine  in,  216;  iron 
in,  217;  kreatinin  in,  208;  lead  in, 
218;  leucinin,  212;  leucocytes  in, 
213  ;  melanin  in,  202  ;  mercury  in, 
218  ;  micro-organisms  in,  216 ;  uaph- 
thalin  in,  219;  organised  sediment 
in,  213;  oxalic  acid  in,  208;    pep- 
tone in,  188;  phenacetine  in,  218 
phenol  in, 209 ;  phosphates  in,  202 
212  ;  potassium  in,  204 ;  pus  in,  213 
216 ;  quantity  of,  181 ;  quinine  in 
219 ;  reaction  of,  183 ;  red  blood-cells 
in,  213;  renal  epithelium  in,  214 
rhubarb  in,  219;  salicylic  acid'  in 
218;  santonin  in,  219;  sediment  in 
210  ;  senna  in,  219 ;  sodium  in,  204 
specific  gravity  of,  182:  sugar  in 
192  :  sulphates  in,  202  :  sulphuretted 
hydrogen  in,  202;  tannin  in,  219 


292 


INDEX 


turpentine  in,  219 :  tyrosin  crystals 
in,  212;  unorganized  sediment  in, 
210:  urobilin  in,  192. 
Urobilin,  test  for,  192. 

Valvular  cardiac  lesions,  177. 
Van  Deen"s  test  for  blood,  189. 
Varicella,  27. 
Variola,  26. 
Varioloid,  27. 
Venous  pulse,  164. 
Ventricular  voice,  109. 
Vermes,  253. 

Vertebra  prominens,  127. 
Vertigo,  37. 

Vesicular  respiration,  136. 
A^essels,  auscultation  of,  170. 
A'ibriones,  270. 
Vital  capacity,  126. 
Vocal  cords,  cadaveric    position  of, 
119 :  paralysis  of,  116  seq. 


Vocal  fremitus,  141. 

Voice,    109 ;     auscultation    of,    141 ; 

threefold  splitting  of,  110. 
Volumen  pulmonum  auctum,  152. 
Vomiting,  77  ;  faecal,  80. 
Vomitus  matutinus,  80 ;  microscopic 

examination  of,  79. 

Wandering  kidney,  225. 

Waxy  casts,  214. 

White  blood-cells,  244 ;  number  of,  244. 

Whooping  cough,  122. 

Widal's  reaction,  272. 

Wintrich's  change  of  sound,  135. 

Worms,  253. 

Wound  fever,  31. 

Xanthin  bodies,  208 ;  stones,  227. 

Yellow  sputum,  145. 

ZOOGL^A,  264. 


A 


List  of  Books  on  Medicine,  Etc. 


ALLBUTT.  —  A  System  of  Medicine.  By  many  Writers.  Edited  by 
Thomas  Clifford  Allbutt,  M.A.,  M.D.,  LL.D.,  F.R.C.P.,  F.R.S., 
F.L.S.,  F.S.A.,  Regius  Professor  of  Physics  in  the  University  of 
Cambridge,  etc.  In  six  vokimes,  medium  8vo.  To  be  issued 
quarterly,  beginning  July,   1896.     (^Orders  received  for  sets  only.^ 

Vol.  I.  Prolegomena  and  Infectious  Diseases.  Cloth,  $5.00.  Half 
Leather,  $6.00.  Illustrated  with  t^t^  Figures  in  the  Text,  13  Charts 
of  Death  Rate,  Temperature,  etc.,  and  a  Colored  Plate. 

Vol.  II.  Infective  Diseases.  Cloth,  ^5,00.  Half  Leather,  $6.00. 
With  77  Figures,  6  Charts,   Map  and  Colored  Plate. 

Vol.  III.     Diseases  of  Obscure  Causation ;  Diseases  of  Alimenta- 
tion and  Excretion.     Cloth,  ^5.00.     Half  Leather,  $6.00. 
Vol.  IV  is  nearly  ready ;    Vols.   V  and  ]'I  in  preparation. 

"  This  is  the  beginning  of  an  elaborate  '  system  '  which  is  destined  to  become  a  very 
important  addition  to  our  literature.  The  work  is  a  pioneer  in  many  directions." —  TAe 
Journal  of  the  A  nierican  Medical  Association. 

"  Although  it  must  of  necessity  follow  that  a  work  which  has  such  a  list  of  contributors 
as  this  has,  will  be  of  a  superior  order,  yet  in  anticipation  one  rather  underestimates  than 
overestimates  its  worth.  As  he  reads,  however,  he  has  ample  evidence  of  the  superiority 
of  the  book  and  perceives  how  unique  in  many  respects  it  is.  To  judge  from  this,  the 
first  volume,  it  is  not  too  much  to  say  that  it,  more  than  most  works  of  similar  compass, 
deserves  the  title  of  system,  for  it  is  comprehensive,  scientific,  and  systematic  in  the 
highest  degree.  .  .  .  The  introduction,  in  particular,  merits  the  warmest  terms  of  ad- 
miration. It  is  written  by  the  editor  himself,  and  for  greatness  of  thought,  broad  compre- 
hensiveness and  beauty  of  language,  is  a  most  able  production."  —  T/ie  Medical  Journal. 
New  York. 

ALLBUTT  and  PLAYFAIR.  — A  System  of  Gynaecology.  By  many 
Authors.  Edited  by  T.  C.  Allbutt,  Editor  of  A  System  of  Medi- 
cine, and  L.  S.  Playfair,  Professor  of  Gynaecology,  King's  College. 
Cloth,  ^6.00.  Half  Leather,  $7.00. 
This  is  uniform  with  the  six-volume  System  of  Medicine,  under  the 
general  editorship  of  Dr.  Allbutt.  To  subscribers  of  that  System, 
entire  (7  volumes  including  the  Gynaecology),  the  price  is  Cloth, 
J555.00.     Half  Leather,  ^6.00. 

I 


A   LIST   OF  BOOKS   ON  MEDICINE,   ETC. 

BALFOUR. — The  Senile  Heart.  Its  Symptoms,  Sequelae,  and  Treat- 
ment.    By  G.  W.  Balfour,  M.D.     I2m9.     Cloth,  $1.50. 

"  A  very  clearly  expressed  and  readable  treatise  upon  a  subject  of  great  interest  and 
importance.     We  can  heartily  commend  this  work."  —  Medical  Record,  New  York. 

BARR.  —  Manual  of  Diseases  of  the  Ear,  including  those  of  the  Nose 
and  Throat  in  Relation  to  the  Ear.  For  the  use  of  Students  and 
Practitioners  of  Medicine.  By  THOMAS  Barr,  M.D.,  Lecturer  on 
Diseases  of  the  Ear,  Glasgow  University.  Second  Edition,  largely 
rewritten.     With  229  Illustrations.     $3.50. 

BRUNTON.  —  On  Disorders  of  Digestion.  Their  Consequences  and 
Treatment.     By  T.  Lauder  Brunton,  F.R.S.     $2.50. 

Lectures  on  the  Action  of  Medicine.     Lectures  on  Pharmacology 

and  Therapeutics,  delivered  at  St.  Bartholomew's    Hospital,   1896. 
By  T.  Lauder  Brunton,  F.R.S.     8vo.     Cloth,  ^4.00. 

CLELAND  and  McKAY.  —  Anatomy  of  the  Human  Body.     By  Dr. 

John  Cleland,  Professor  of  Anatomy  in  the  University  of  Glasgow, 

and  Dr.  John  Yule  McKay,  Professor  of  Anatomy  in  University 

College,  Dundee.     8vo.     Cloth,  ^6.50. 

The  object  of  the  authors  has  been  to  produce  a  work  that  should  be  accurate,  com- 
prehensive, up  to  date,  and  yet  sufficiently  brief  for  the  use  of  students. 

FOSTER.  —  A  Text-book  of  Physiology.  By  Michael  Foster,  M.A., 
M.D.,  LL.D.,  F.R.S.,  Professor  of  Physiology,  University  of  Cam- 
bridge, Fellow  of  Trinity  College,  Cambridge.  8vo.  Illustrated. 
Sixth  edition,  largely  revised. 

Part  I.     Blood  ;  the  Tissues  of  Movement ;  Vascular  Mechanism. 

^2.60. 

Part  II.     The  Tissues    of    Chemical    Action ;    Nutrition.      Ahzv 

Edition  in  Press.     ^2.60. 
Part  III.     The  Central  Nervous  System.     New  Edition.    $2.50. 
Partly.     The  Central  Nervous  System  {concluded)-,  the  Tissues 

and  Mechanisms  of  Reproduction.     $2.00. 

Party.     (Appendix.)     The  Chemical  Basis  of  the  Animal  Body. 

By  A.  Sheridan  Lea,  ScD.,  F.R.S.     $1.75. 
Text-book  of  Physiology.     Revised  and  Abridged  from  the  work  de- 
scribed above  to  one  volume.     8vo.     Cloth,  $5.00.     Sheep,  ;$6.oo. 

"  We  have  used  this  valuable  work  (for  the  most  part  in  the  five-volume  edition) 
since  its  first  publication,  and  will  continue  to  do  so."  —  V.  C.  Vaughan,  Dean  of  Medi- 
cal Dept..  Utiiversity  of  Michigan. 

2 


A   LIST   OF  BOOKS  ON  MEDICINE,   ETC. 


"  The  abridgment  is  much  better  adapted  to  the  use  of  medical  students  than  the  five- 
volume  edition,  and  we  are  recommending  it  to  our  students  as  the  best  existing  English 
text-book  of  physiology  for  their  use." — Frederic  S.  Lee,  Adjunct  Professor  of 
Physiology,  Columbia   University. 

"  I  am  much  pleased  with  the  form  in  which  this  edition  is  issued,  since  it  makes  it 
more  suitable  as  a  text-book  for  students,  and  removes  some  of  the  objections  which  have 
hitherto  attended  the  use  of  the  former  editions.  It  is  compact  so  far  as  its  subject-mat- 
ter goes,  and  the  abridgment  is  a  great  improvement.  I  shall  take  pleasure  in  pointing 
out  this  fact  to  my  students." ^Charles  D.  Smith,  Professor  of  Physiology,  Boivdoin 
College. 

"  I  have  for  several  years  recommended  thi.s  text-book  to  my  classes  in  the  Medical 
Department  of  the  University  of  California,  and  have  always  regretted  that  the  edition 
they  were  compelled  to  purchase  was  not  an  authorized  one.  I  shall  take  pleasure 
hereafter  in  recommending  your  edition  to  my  students."  —  A.  A.  D'Ancon'a,  Professor 
of  Physiology,  University  of  California. 

FOTHERGILL.  —  The  Practitioner's  Handbook  of    Treatment;    or, 

The  Principles  of  Therapeutics.  By  the  late  J.  Milner  Fother- 
GILL.  Edited,  and  in  great  part  rewritten  by  \V.m.  Murrell. 
Fourth  Edition.     8vo.     Cloth,  $5.00. 

FOTHERGILL.  —Manual  of  Midwifery.     For  the  Use  of  Students  and 

Practitioners.      By  W.  E.  Fothergill,  M.A.,  B.Sc,  M.B.,  CM.; 

Buchanan   Scholar   in    Midwifery,  University  of   Edinburgh,    etc. 

With  Double  Colored  Plate  and  Sixty-nine  Illustrations  in  the  text. 

l2mo.     Cloth,  ^2.25. 

"  This  work  is  a  modern  handbook  on  obstetrics,  and  not  only  the  student,  but  the 
practitioner  and  some  writers  on  allied  topics  may  gain  a  large  quota  of  knowledge  from 
its  reading.     The  book  is  a  safe  teaching  guide  and  a  most  excellent  handbook."  —  The 

Medical  Journal,  New  York. 

FROST.  — The  Fundus  Oculi.  With  an  Ophthalmoscopic  Atlas  illus- 
trating its  Physiological  and  Pathological  Conditions.  By  W. 
Adams  Frost,  F.R.C.S.,  Ophthalmic  Surgeon,  St.  George's  Hos- 
pital, etc.     4to.     Cloth,  gilt  top,  $18.00. 

"  The  direct,  concise,  and  lucid  manner  in  which  the  descriptions  of  the  various  con- 
ditions are  given  is  truly  admirable.  Exhaustive  without  being  verbose,  complete  in 
facts  without  being  confusing,  the  conception  and  completion  of  the  argument  leaves 
little  to  be  desired.  Too  much  cannot  be  said  in  praise  of  the  colored  plates." —  The 
Medical  Record,  New  York. 

HAMILTON.  —  A  Systematic  and  Practical  Text-book  of  Pathology. 
By  D.  J.  Hamilton,  M.D.     Cloth.     Svo. 

Vol.  I.     Technical.     General    Pathological   Processes.      Diseases 
of  Special  Organs.     S6.25. 

Vol.  II.     Diseases  of  Special  Organs  {continued^.    Bacteriology, 
etc.     2  parts.     Each,  35.00. 

"  This  is  beyond  question  the  most  complete  work  on  pathology  in  the  English  lan- 
guage today.  The  author  has  accomplished  his  laborious  task  most  successfully.  We 
cannot  better  criticise  it  than  by  saying  it  is  beyond  criticism."  —  Canada  Medical 
Record. 


A   LIST   OF  BOOKS  ON  MEDICINE,   ETC. 

HAWKINS.  — On  Diseases  of  the  Vermiform  Appendix.  With  a  Con- 
sideration of  the  Symptoms  and  Treatment  of  the  Resulting  Forms 
of  Peritonitis.     By  H.  P.  Hawkins,  F. R.C.P.     8vo.     $2.25. 

"An  excellent  review  of  the  subject,  particularly  in  its  pathological,  statistical,  and 
therapeutical  bearings." —  The  Medical  Record,  New  York. 

ILLOWAY.  —  Constipation  in  Adults  and  Children.  With  special  ref- 
erence to  Habitual  Constipation  and  its  most  successful  Treatment 
by  the  Mechanical  Methods.  By  H.  Illoway,  M.D.,  formerly  Pro- 
fessor of  the  Diseases  of  Children,  Cincinnati  College  of  Medicine 
and  Surgery.  With  many  plates  and  illustrations.  8vo.  Cloth, 
^4.00. 

"  We  are  extremely  glad  to  note  the  appearance  of  a  work  of  such  great  practical  im- 
portance as  this  produced  by  Dr.  Illoway.  .  .  .  Indeed,  the  author's  description  of  the 
mechanical  methods  for  overcoming  habitual  constipation  and  their  application  deserves 
general  reading."  —  Mevipliis  Medical  Monthly 

"  The  author  of  this  book  has  supplied  a  much  needed  work  on  the  subject  of  constipa- 
tion. The  frequency  and  unpleasant  complications  of  this  pathological  condition  make 
a  demand  for  a  reliable  and  instructive  treatise  thereon:  such  is  found  in  thi^  book."  — 
Eclectic  Medical  Journal. 

"  It  is  a  very  valuable  contribution,  and,  in  fact,  the  only  complete  monograph  on  the 
subject  in  recent  days  of  which  we  have  knowledge."  —  Virginia  Medical  Monthly. 

JENNER. — Lectures  and  Essays  on  Fevers  and  Diphtheria,  1849- 
1879.     By  Sir  William  Jenner.     8vo.    $4.00. 

"  This  volume  was  a  fitting  exemplar  of  the  careful  and  scientific  work  that  has 
placed  the  author  in  the  foremost  rank  of  his  profession.  It  cannot  fail  to  prove  interest- 
ing to  physicians."  —  The  Medical  Journal,  New  York. 

Clinical  Lectures  and  Essays  on  Rickets,  Tuberculosis,  Abdomi- 
nal Tumors,  and  Other  Subjects.     Svo.    $4.00. 

"  Rarely  are  collected  in  a  single  volume  of  small  size  so  much  of  valuable  clinical 
material  as  can  be  found  herein.  The  ripe  experience,  broad  views,  and  soundness  of 
judgment  of  the  author  are  manifest  in  a  striking  degree,  and  make  the  subject  not  only 
interesting  but  instructive.  The  commendable  endeavor  to  make  all  the  varied  patho- 
logical conditions  present  in  these  common  and  wide-spread  diseases  accord  with  the 
well-recognized  symptoms  so  often  presented,  rounds  out  the  subjects  with  a  completeness 
of  description  and  practical  interest  which  cannot  fail  to  give  new  points  of  view  to  every 
reader  and  new  ideas  to  every  student."  —  The  Medical  Record,  New  York. 

KIMBER.  —  Text-book  of  Anatomy  and  Physiology  for  Nurses.  Com- 
piled by  Diana  Clifford  Kimber,  graduate  of  Bellevue  Training 
School;  Assistant  Superintendent  New  York  City  Training  School, 
Blackwell's  Island,  N.Y.;  formerly  Assistant  Superintendent  Illinois 
Training  School,  Chicago.     Fully  Illustrated.     Svo.     $2.50. 

"  From  her  long  experience  in  teaching  classes  the  author  knows  exactly  what  nurses 
need  and  how  much  can  be  reasonably  given  them  in  the  short  space  of  two  years'  time, 
and  for  the  assistance  of  the  inexperienced  teacher  her  book  is  arranged  in  lessons  cover- 
ing the  first  or  junior  year.  The  subjects  are  presented  with  sincerity  and  distinction, 
and  illustrated  by  cuts  and  plates  of  unusual  merit  "       The  'Trained  Nurse. 


A   LIST    OF  BOOKS   ON  MEDICINE,   ETC. 


"  A  happy  mingling  of  theoretical  knowledge  with  the  requisite  technical  instruction 
required  by  practical  work  seems  to  have  been  attained  in  this  volume.  The  lessons  are 
progressive  and  so  arranged  as  to  unfold  anatomy  and  physiology  to  nurses  in  a  natural, 
helpful  manner.  The  physiological  discussions  follow  easily  upon  anatomical  descriptions 
in  such  a  manner  as  to  make  an  impression  upon  the  student. 

"  The  volume  is  beautifully  printed  and  well  illustrated,  and  the  author  deserves  much 
credit  for  her  work  as  compiler.  The  glossary  and  index  are  especially  satisfactory."  — 
7'/ie  Johns  Hopkins  Hospital  Bulletin. 

KOCHER.  —  Text-book  of  Operative  Surgery.  By  Dr.  Theodor 
Kocher,  Professor  of  Surgery  and  Director  of  the  Surgical  Clinic 
in  the  University  of  Bern.  Translated  with  the  Special  Authority 
of  the  Author  from  the  Second  Revised  and  Enlarged  German  Edi- 
tion by  Harold  J.  Stiles,  M.B.,  F.R.C.S.  Edin.,  Senior  Demon- 
strator of  Surgery,  University  of  Edinburgh,  etc.  With  185  Illustra- 
tions.    8vo.     ^3.50.     New  edition  in  preparation. 

"  This  is  a  translation  of  the  second  edition  of  Dr.  Kocher's  excellent  treatise  on 
operative  surgery,  which  has  already  won  for  itself  recognition  as  the  standard  work  on 
this  subject.  The  translation  has  been  well  done,  and  the  illustrations  are  admirable."  — 
The  Medical  Record,  New  York. 

MACDONALD.  —  A  Treatise  on  Diseases  of  the  Nose  and  its  Acces- 
sory Cavities.    By  Greville  MacDonald,  M.D.    Second  Edition. 

Svo.     $2.50. 

"  The  author  has  adopted  a  method  of  indexing  his  work  that  is  sure  to  commend  it 
to  general  favor — table  of  contents,  chapter-indexing,  and  marginal  notes.  The  busy 
man  is  always  grateful  when  he  is  enabled  by  any  such  device  to  find  at  a  glance  the 
division  of  the  subject  that  particularly  interests  him,  and  when,  moreover,  he  finds,  on 
consulting  the  text,  that  the  author  has  written,  so  to  speak,  with  the  patient  before  him, 
his  attention  and  confidence  are  entirely  gained  and  he  follows  with  the  closest  attention 
the  lessons  of  one  who  has  seen  and  understood.  Macdonald's  style  is  admirably  adapted 
to  his  subject,  which  latter  he  keeps,  without  deviation,  constantly  before  his  eyes.  We 
cannot  too  highly  recommend  the  treatise." —  The  Medical  Journal,  New  York. 

MACEWEN. — Pyogenic   Infective   Diseases  of  the  Brain  and  the 

Spinal   Cord,  Meningitis,  Abscess   of  Brain,  Infective  Sinus 

Thrombosis.      By  Wh.liam    Macewen,  M.D.   (Glasgow).     Svo. 

Buckram,  ^6.00. 

"  The  careful,  preci.se  methods  followed  by  the  author,  his  thorough  familiarity  with 
cerebral  anatomy  and  surgery,  and  his  habit  of  waiting  for  time  to  demonstrate  the  value 
of  what  he  has  done,  make  this  volume  the  most  valuable  contribution  to  the  surgery 
of  the  brain  that  has  appeared  in  several  years.  The  illustrations  are  magnificent,  on 
a  par  with  those  in  his  beautiful  Atlas  of  Head  Sectiotis.  The  volume  must  be  of  great 
interest  to  the  neurologist,  the  aurist,  and  the  surgeon." —  The  Medical  Journal,  New 
York. 

Atlas  of  Head  Sections.  53  Engraved  Copperplates  of  Frozen  Sec- 
tions of  the  Head  and  53  Key  Plates  with  Descriptive  Text.  By 
William  Macewen,  M.D.     Folio.     Bound  in  Buckram,  $21.00. 

"The  Atlas  should  certainly  be  in  the  hands  of  every  surgeon  who  aspires  to  enter 
the  field  of  brain-surgery,  as  a  careful  inspection  of  these  plates  will  teach  more  than 
many  volumes  written  upon  the  subject." —  The  Medical  Record,  New  York. 


A    LIST   OF  BOOKS   ON  MEDICINE,    ETC. 


MINOT. — Human  Embryology.  By  Charles  Sedgwick  Minot,  Pro- 
fessor of  Histology  and  Human  Embryology,  Harvard  Medical 
School,  Boston.     With  463  Illustrations.     8vo.     $6.00. 

PLAYFAIR. — A  System  of  Gynaecology,  under  the  editorship  of  Dr. 
W.  S.  Playfair,  is  issued  also  as  an  independent  volume,  and 
can  be  purchased  separately  by  those  who  do  not  care  for  the  Sys- 
tem of  Medicine,  edited  by  Dr.  Allbutt,  in  connection  with  which 
it  is  issued.  If  bought  apart  from  the  System  of  Medici^ie  the  price 
will  be,  Cloth,  $6.00,  Half  Leather,  $7.00. 

STARR.  —Atlas  of  Nerve  Cells.  By  M.  Allen  Starr,  M.D.,  Ph.D., 
Professor  of  Diseases  of  the  Mind  and  Nervous  System,  College  of 
Physicians  and  Surgeons,  Medical  Department,  Columbia  College  ; 
Consulting  Neurologist  to  the  Presbyterian  and  Orthopaedic  Hos- 
pitals, and  to  the  New  York  Eye  and  Ear  Infirmary.  With  the 
cooperation  of  Oliver  S.  Strong,  A.M.,  Ph.D.,  Tutor  in  Biology, 
Columbia  College,  and  Edward  Leaming.  Illustrated  with  53 
Albert-type  Plates  and  13  Diagrams.  Columbia  University  Press. 
Royal  4to.     Cloth,  $10.00. 

"  The  paper,  typography,  and  beautifully  reproduced  plates  of  this  quarto  atlas  give  it 
the  appearance  of  an  editioft  de  luxe.  .  .  .  The  explanation  of  the  plates  and  the  expo- 
sition of  the  subject  display  the  clear,  concise,  and  comprehensive  style  characteristic  of 
Dr.  Starr." —  The  Medical  Record,  New  York. 

"  Dr.  Starr's  work  will  enable  the  numerous  students  and  practitioners  who  cannot 
undertake  original  research  to  understand  completely  the  new  facts  which  have  been  dis- 
closed. The  reproductions  of  micro-photographs  leave  nothing  to  be  desired,  and  the 
details  of  nerve  structure  are  shown  with  the  minutest  accuracy  and  with  the  most  perfect 
clearness.  ...  In  the  opinion  of  the  London  Times,  '  their  work  will  be  indispensable 
to  all  who  desire  to  become  familiar  with  the  anatomy  of  the  nervous  system.'" —  T/ie 
Eveniiig  Sun,  New  York. 

STEPHENSON.  —  Epidemic  Ophthalmia.  Its  Symptoms,  Diagnosis  and 
Management.  With  papers  upon  Allied  Subjects.  By  Sidney 
Stephenson,  M.B.,  F.R.C.S.  Ed.     8vo.     Cloth,  $3.00. 

"This  is  an  elaborate,  scientific  and  practical  treatise  on  a  subject  of  wide  economic 
and  social  interest.  It  is  divided  into  four  sections.  The  first  treats  of  epidemic  ophthal- 
mia, its  symptoms,  diagnosis,  and  management.  The  second  consists  mainly  of  a  clinical 
inquiry  into  the  prevalence  and  significance  of  the  follicular  granulation  of  the  conjunc- 
tiva. The  third  is  devoted  to  the  treatment  of  trachoma  and  its  complications,  and  the 
fourth  to  the  treatment  of  follicular  conjunctivitis.  There  is  a  good  index  of  subjects  and 
authors,  also  a  list  of  the  works  consulted." —  The  Medical  Journal,  New  York. 

THOMA.  — Text-book  of  General  Pathology  and  Pathological  Anat- 
omy. By  Richard  Thoma.  Translated  by  Alexander  Bruce, 
M.D.,  F.R.C.P.E.,  etc..  Lecturer  on  Pathology,  Surgeon's  Hall, 
Edinburgh,  etc.  With  436  Illustrations.  Vol.  I.  Imp.  8vo.  Cloth, 
^7.00. 

6 


A   LIST  OF  BOOKS   ON  MEDICINE,   ETC. 


"  The  first  volume  of  this  well-known  work    constitutes  one  of  the   most   valuable 

contributions  to  the  subject  in  any  language,  and  English-speaking  readers  are  to  be  con- 
gratulated upon  its  translation  from  the  German.  .  .  .  Too  much  praise  can  hardly  be 
given  to  the  work  of  the  translator.  The  diction  is  always  pure  and  readily  intelligible, 
the  author's  meaning  reappears  accurately,  and  there  is  an  entire  absence  of  the  traces 
of  foreign  style  so  frequently  found  in  English  translations  of  German  medical  works. 
Finally,  the  publishers  have  presented  a  volume  which  in  binding,  paper,  printing,  and 
general  detail  is  of  a  very  high  order."  —  The  Medical  Journal,  New  York. 

TUBBY.  —  Deformities.  A  Treatise  on  Orthopaedic  Surgery,  for  Prac- 
titioners and  Advanced  Students.  By  A.  H.  Tubby,  M.S.,  F.R.C.S. 
Eng.,  Assistant-Surgeon  to  and  in  charge  of  the  Orthopaedic  Depart- 
ment, Westminster  Hospital.  Illustrated  with  15  Plates  and  302 
Figures,  of  which  200  are  original,  and  by  Notes  of  100  Cases. 
Large  8vo.     Cloth,  S5.50. 

"This  volume  is  the  outcome  of  several  years'  work,  by  the  author,  at  the  National 
Orthopaedic  Hospital,  the  Evelyn  Hospital  for  Sick  Children,  and  for  some  time  in  the 
Orthopaedic  Department  at  the  Westminster  Hospital.  The  author,  however,  has  not 
only  made  a  record  of  his  own  work,  but  has  given  a  fair  account  of  the  deformities  as  at 
present  understood.  It  is  pleasing  to  note  that  he  has  quoted  freely  from  Bradford  and 
Lovett  of  this  country,  and  pays  a  graceful  tribute  to  our  Orthopaedic  Association  by  say- 
ing: '  Above  all,  I  cannot  omit  to  express  my  sense  of  indebtedness  to  the  many  admira- 
ble writers  who  have  recorded  their  experiences  in  the  Transactions  of  the  American 
Orthopaedic  Association.'  .  .  . 

"  The  book  is  timely  and,  although  conservative,  is  fully  up  to  date.  .  .  .  We  com- 
mend the  book  as  one  being  in  every  way  satisfactor>^" —  The  Joiirnal  of  the  Ameri- 
can Medical  Association. 

UNNA.  —  The  Histopathology  of  the  Diseases  of  the  Skin.  By  Dr. 
P.  G.  Unna.  Translated  from  the  German,  aided  by  the  Author,  by 
Norman  Walker,  M.D.,  F.R.C.P.,  Assist.  Physician  in  Dermatol- 
ogy to  the  Royal  Infirmary,  Edinburgh.  With  a  Double  Colored 
Plate  containing  Nineteen  Illustrations  and  Forty-two  Additional 
Illustrations  in  the  Text.     Cloth,  ^10.50. 

"Dr.  Unna  has  given  us  a  great  book;  in  its  twelve  hundred  pages  there  is  much 
that  is  valuable  and  there  is  considerable  that  is  new.  ...  It  is  sufficient  to  say  that  the 
book  will  no  doubt  prove  a  valuable  addition  to  the  shelves  of  those  who  are  working  in 
the  line  of  its  subject-matter." —  The  Medical  Journal,  New  York. 

WARING.  — Diseases  of  the  Liver,  Gall  Bladder,  and  Biliary  System. 
Their  Pathology,  Diagnosis,  and  Surgical  Treatment.  By  H.  J. 
Waring,  M.S.,  B.Sc.  Lond.,  F.R.C.S.,  St.  Bartholomew's  Hospital, 
London.     8vo.     $3.75. 

WATSON.— Practical  Handbook  of  the  Diseases  of  the  Eye.  Con- 
taining Nine  Colored  Plates  and  Twenty-four  Illustrations  in  the 
Text.  By  D.  Chalmers  Watson,  M.B,,  CM.,  Ophthalmic  Surgeon, 
Marshall  Street  Dispensary,  Edinburgh.      i6mo.     $1.60. 

7 


A   LIST  OF  BOOKS  ON  MEDICINE,   ETC. 

WEBSTER.  —  Ectopic  Pregnancy.  Its  Etiology,  Classification,  Embry- 
ology, Diagnosis,  and  Treatment.  By  J.  Clarence  Webster,  M.D., 
F.R.C.P.  Ed.,  Assistant  of  the  Professor  of  Midwifery,  etc.,  University 
of  Edinburgh.     With  Eighty  Illustrations.     8vo.     Cloth,  ^3.75. 

WILSON.  —  An  Atlas  of  the  Fertilization  and  Karyokinesis  of  the 

Ovum.     By  Edmund  B.  Wilson,  Ph.D.,  Professor  in  Invertebrate 

Zoology  in  Columbia  College,  with  the  Cooperation  of  Edward 

Leaming,  M.D.,  F.R.P.S.,  Instructor  in  Photography  at  the  College 

of  Physicians  and  Surgeons,  Columbia  College.     4to.     $4.00. 

"  This  work  is  of  a  very  high  order,  and  both  by  its  merit  and  its  opportuneness  is  a 
noteworthy  contribution  to  science.  .  .  .  The  work  takes  its  place  at  once  as  a  classic, 
and  is  certainly  one  of  the  most  notable  productions  of  pure  science  which  have  appeared 
in  America.  It  will  be  valuable  to  every  biologist,  be  he  botanist  or  zoologist,  be  he  in- 
vestigator or  teacher."  —  Science. 

The  Cell  in  Development  and  Inheritance.     By  Edmund  B.  Wil- 
son, Ph.D.     With  Illustrations.     $3.00. 

ZIEGLER.  — A  Text-book  of  Pathological  Anatomy  and  Pathogene- 
sis. With  Illustrations.  By  Ernst  Ziegler,  Professor  of  Pathol- 
ogy in  the  University  of  Freiburg.  Translated  by  Donald  Mac- 
allister,  M.A.,  M.D.,  Cambridge,  and  Henry  W.  Cattell,  A.M., 
M.D.,  Demonstrator  of  Morbid  Anatomy,  University  of  Pennsyl- 
vania.    8vo. 

Vol.  I.     General  Pathological  Anatomy.     New  Edition.     In  Prep- 
aration. 

Vol.  II.     Special   Pathological   Anatomy.      New   Edition.      Thor- 
oughly Revised.     Sections  I-VIII.     $4.00. 

This  is  a  thoroughly  revised  and  entirely  reset  edition  of  the  standard  text-book.  In 
its  revision  the  latest  German  edition  has  been  consulted  throughout  and  the  book  is 
practically  a  new  translation.     A  valuable  index,  etc.,  has  been  added  by  Dr.  Cattell. 

The  Same.     Sections  IX-XV.     Just  Ready.     ^4.00. 


PUBLISHED    BY 

THE   MACMILLAN   COMPANY, 

66  Fifth  Avenue,  New  York. 
8 


